THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 

SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


ORAL  SEPSIS 

IN  ITS  RELATIONSHIP  TO 

SYSTEMIC  DISEASE 


OKAL  SEPSIS 


SYSTEMIC  DISEASE 


BY 

WILLIAM  W-lDUKE,  M.D.,  Pn.B. 

KANSAS  CITY,  Mo. 

PROFESSOR   OF   EXPERIMENTAL    MEDICINE   IN   THE   UNIVERSITY    OF   KANSAS 

SCHOOL  OF  MEDICINE;  PROFESSOR  IN  THE  DEPARTMENT  OF  MEDICINE  IN 

WESTERN  DENTAL  COLLEGE;  VISITING  PHYSICIAN  TO  CHRISTIAN 

CHURCH  HOSPITAL;  CONSULTING  PHYSICIAN  TO  KANSAS 

CITY  GENERAL  HOSPITAL,  KANSAS  CITY,  MO.,  AND 

TO  ST.  MARGARET'S  HOSPITAL,  KANSAS 

CITY,  KANSAS. 


WITH  170  ILLUSTRATIONS 


ST.  LOUIS 
C.  V.  MOSBY  COMPANY 

1918 


COPYRIGHT,  1918,  BY  C.  V.  MOSBY  COMPANY 


Press  of 

C.  V.  Mosby  Company 
St.  Louis 


Bicmedicsl 
Library 

wu 


TO  MY  FATHER 
HENRY  BUFORI)  DUKE 

THIS  BOOK 

IS  AFFECTIONATELY 

DEDICATED 


577956 


PREFACE 


In  the  preparation  of  this  little  book,  the  aim  has  been 
to  present  as  briefly  and  clearly  as  possible  the  rather 
complex  relationship  which  frequently  exists  between 
infections  of  the  gum  and  alveolar  process  and  certain 
systemic  disorders.  This  has  necessarily  involved  a  dis- 
cussion of  some  of  the  more  complex  problems  of  bacteri- 
ology, immunology,  and  pathology  as  well  as  of  dentistry. 
In  so  small  a  space  it  has  not  been  possible  to  take  up 
any  of  these  subjects  in  great  detail,  and  for  this  reason 
those  especially  interested  in  certain  particular  phases 
are  referred  to  the  writings  of  Eosenow,  Billings,  Schott- 
muller,  Poynton  and  Payne,  Libman,  Vaughan,  von  Pir- 
quet,  Wolff-Eisner,  Richet,  Rosenau  and  Anderson,  and 
other  investigators  to  whom  we  are  indebted  for  many 
of  our  more  recent  ideas  which  have  a  bearing  upon  this 
very  important  subject. 

In  the  opinion  of  the  writer,  the  discovery  of  the  rela- 
tionship which  frequently  exists  between  the  various 
chronic  infections  and  systemic  disease  marks  a  great 
practical  advance  in  the  science  and  therapy  of  medicine. 
For  centuries  it  has  been  evident  to  physicians  that  cer- 
tain acute  inflammatory  lesions  give  rise  to  systemic  dis- 
turbances. One  of  the  main  advances  of  recent  years, 
therefore,  has  been  the  disclosure  of  the  fact  that  small 
and  apparently  innocent  infections  which  give  rise  to  lit- 
tle or  no  local  disturbance  may  likewise  be  the  source  of 
serious  generalized  disease. 

For  the  proper  care  of  medical  cases,  the  hearty  and 
intelligent  cooperation  of  the  dentists  is  absolutely  es- 
sential. In  the  writer's  experience,  it  has  been  found 

7 


8  PREFACE 

that  the  teeth  should  be  taken  into  account  in  nearly 
every  medical  case.  For  this  reason,  the  welfare  of  the 
affected  individual  demands  that  the  dental  surgeon  un- 
derstand and  appreciate  the  problems  and  aims  of  the 
physician,  and  that  he  be  willing  at  times  to  sacrifice 
apparently  useful  teeth  for  the  sake  of  the  patient 's  gen- 
eral welfare.  Consequently,  the  main  purpose  of  this 
volume  has  been  to  assemble  facts  which  show,  first  of 
all,  that  dental  sepsis  is  an  extremely  common  condition, 
and,  second,  that  it  may  cause  serious  systemic  disorder 
in  many  different  ways. 

For  the  sake  of  completeness,  it  has  been  necessary  to 
discuss  some  of  the  purely  dental  problems.  These  have 
been  discussed  purely  from  a  pathologic  viewpoint  based 
upon  an  experience  with  more  than  one  thousand  care- 
fully studied  medical  cases  observed  in  a  consulting  of- 
fice practice  on  whom  dental  roentgenograms  were  made 
as  part  of  a  routine  examination.  In  all  over  eight  thou- 
sand dental  films  were  taken.  It  is  believed  and  sincerely 
hoped  that  the  views  here  expressed  are  in  harmony  with 
those  of  the  dental  surgeons  who  have  given  the  problem 
of  oral  sepsis  the  attention  and  study  it  deserves.  For 
a  more  detailed  account  of  this  subject  from  a  dental 
standpoint,  the  reader  is  referred  to  the  publications  of 
the  investigators  in  this  field:  G.  V.  Black,  and  A.  D. 
Black,  Hartzell,  Price,  Rhein,  Thoma,  Grieves,  etc. 

Finally,  I  wish  to  acknowledge  with  thanks  the  hearty 
cooperation  of  my  friend  and  coworker  in  this  study, 
Rex  Dively,  under  whose  direction  the  roentgenologic 
work  was  done,  to  L.  S.  Milne  and  W.  A.  Myers,  my 
office  associates,  to  Joseph  Kelly  and  Miss  Rose  Mary 
Trott,  for  their  careful  work  in  clinical  pathology,  and 
to  Miss  Elizabeth  Leas,  assistant  in  the  roentgenologic 
laboratory. 

WILLIAM  W.  DUKE. 

Kansas  City,  Mo. 


CONTENTS 


CHAPTER  I 

INTRODUCTION 

PAGE 

History 17 

Publication   of   Benjamin   Rush   on   the   Relationship   Between   Defective 

Teeth  and  111  Health 17 

General  Observations  Concerning  a  Relationship  Between  Defective  Teeth 

and  111  Health ".......  20 

Relative  Importance  of  Caries,  Malocclusion,  Infection  of  Food,  Pyorrhea, 

and  Alveolar  Abscesses  in  the  Causation  of  Systemic  Disease     .  21 

Frequent   Occurrence    of    Oral    Sepsis 22 

Variation  of  Oral  Sepsis  with  Age  and  Dental  Work,  etc 22 

Aims  of  the  Dentist  in  the  Past  and  at  Present  23 


CHAPTER  II 

PYOKRHEA  ALVEOLARIS 

Ktiologir,    Factors 24 

Brief  Discussion  of : 

Microorganisms 24 

Mechanical   factors 24 

Relative  importance  of  the  various  factors 25 

Frequency  with  which  several  factors  coexist  and  its  cause     ....  26 

The  Role  Played  By: 

Infection .  27 

Various    microorganisms ,     ....  28 

Mechanical    factors 32 

Lowered  resistance  to  infection 32 


CHAPTER  III 

ALVEOLAR  ABSCESSES 

Sources  of  Origin - ...     37 

Statistics  Concerning  the  Occurrence  of  Alveolar  Abscesses 37 

Sources  of  Infection  of  Root  Pulp 42 

9 


10  CONTENTS 

PAGE 
Statistics  Concerning  the  Relative  Frequency  with  which   Treated  Teeth 

Become  Infected 42 

Teeth  purposely  devitalized 4.°> 

Crowned  teeth  not  purposely  devitalized 45 

Root  remnants 45 

Pathology  of  Alveolar  Abscesses 46 

Mode  of  development 46 

Time  of  onset 47 

Symptoms  of  Alveolar  Abscesses 47 

Symptoms  of  acute  abscesses 47 

Osteomyelitis  of  jaw 49 

Symptoms  of  chronic  abscesses 49 

Diagnosis  of  Alveolar  Abscesses 50 

Interpretation  of  roentgcnograms 50 

Significance   of  radioluccnt   areas 52 

Significance   of    radiolucent    areas   in   bone   other   than    that    of    the 

alveolar  process 52 

Comparison   Ixjtween   infection   in   the   alveolar   process   and   that    in 

the  bone  elsewhere  in  the  body 53 

Viability  of  Organisms  in  Alveolar  Abscesses 56 

Importance  of  the  Root  Canal  and  Necrotic  Roots  as  a  Source  of  Reinfec- 
tion of   healing   abscesses 56 

Treatment  of  Periapical  Infections 57 

Illustrations  of  Palliative  Measures  in  the  Treatment  of  Alveolar  Abscesses  59 
Importance   of  Careful  Root  Canal  Work  Immediately  after  Devitaliza- 

tion    of    a    Tooth  67 


CHAPTER  IV 

METASTATIC  INFECTION 

Spread  of  Infection  from  a  Primary  Focus 71 

Influence  of  Lowered  Resistance  to  Infection 71 

Streptoeoccic  Infections 72 

Selective    affinity   of    streptococci 72 

Transmutation   of   species   of   streptococci 72 

Relation  of  selective  affinity  to  virulence  of  organisms 74 

Diseases  which  may  be  caused  by  streptococci 74 

General  Virulence  of  Organisms 75 

The  Role  of  Local  Injury  in  Determining  Site  of  Localization  of  Infection  75 
Relation  of  Local  Injury  in  Determining  the  Nature  of  the  Pathologic 

Process  Caused  by  Infection 76 

Comparison  Between  the  Result  of  Infection  in  Normal  Individuals  and 

Those  Subjected  to  Various  Poisons,  Injury,  Strain,  etc.     ...  77 
Comparison  Between  the  Effect  of  Poisons,  Injury,  Strain,  etc.,  upon  Nor- 
mal Individuals  and  Those  Having  Chronic  Infections     ....  77 


CONTENTS  11 

CHAPTER  V 

NONRELATED  INFECTION  AS  INFLUENCED 
BY  ORAL  SEPSIS 

PAGE 

Influence  of  One  Infection  upon  Another 79 

Acute   infections 79 

Chronic    infections 79 

111  Effects  of  Sepsis  upon  Individuals  with  Syphilis  of  the  Nervous  System  80 
Illustration  of  the  influence  of  an  acute  infection  upon  the  symptoms 

of    tabes    dorsalis 81 

Illustration  of  the  effect  of  chronic  sepsis  in  a  case  of  general  paresis  82 
Illustration  of  the  relief  obtained  by  the  removal  of  sepsis  in  a  severe 

rapidly  progressive  case  of   tabes   dorsalis 82 

Conclusions  Concerning  the  111  Effect  of  Sepsis  upon  Patients  with  Syphilis 

of  the  Central  Nervous  System 83 

Importance  of  Eradicating  Sepsis  as  a  Preliminary  Step  in  the  Treat- 
ment of  Syphilis  of  the  Central  Nervous  System 83-84 

CHAPTER  VI 

TOXIC  EFFECT  OF  ORAL  SEPSIS 

Niiluro  of  the   Toxic  Products  Formed  by  Organisms  Which   Ordinarily 

Take  Part  in  the  Pathology  of  Oral  Sepsis 85 

Allergy  as  Illustrated  by  the  Action  of  Tuberculin 85 

Comparison  Between  a  Tuberculin  Reaction  and  that  Produced  by  In- 
oculation   with    Living    Bacilli 86 

Comparison  Between  Tuberculous  Infections  and  Other  Infections     .     .       86 
Comparison  Between  the  Local,  General,  and  Focal  Reactions  Observed 
Clinically    After    the    Use    of    a   Vaccine,    etc.,    and    After   the 

Acute  Onset  of  a  New  Infection 87 

Influence  of  Acute  and  Chronic  Infections  upon  Chronic  Infections  in 

Gum    and    Alveolar   Process 88 

Influence  of  Oral  Sepsis  upon  Other  Coexisting  Infections  Localized  in 

Remote  Organs 88 

Untoward   Effects   Occasionally   Caused   by   the   Extraction   of   Infected 

Teeth 88 

Beneficial  Results   Frequently   Obtained   by   the   Extraction   of   Infected 

Teeth 89 

Functional   Disturbance    in   Infected    Organs    as    a    Result    of    a    Toxic 

Effect   of  Oral   Sepsis 90 

Sensitization    and    Tolerance    for    Bacterial    Proteins 90 

Relation  Between  the   Systemic   Effect   of   an   Infection   and   Sensitiza- 
tion and   Tolerance 91 

Sensitization  against   Proteins   not   of   Bacterial   Origin 91 

Symptoms   of   Anaphylaxis   in   Animals 92 

Symptoms   of   Anaphylaxis   in   Humans 92 


12  CONTENTS 

PAGE 

Scnsitization 93 

Methods  of  Producing  Artificial  Scnsitization 93 

Protein   Scnsitization   as   Observed   Clinically 93 

Examples  Showing  High  Degree  of  Protein  Sensitization  in  Humans  .  .  93 
Comparison  Between  Protein  Sensitization  as  Seen  Clinically  and 

Experimentally 95 

Oral  Sepsis  as  a  Cause  of  Protein  Sensitization  and  Intoxication     ...  95 

Chronic  Mild  Anaphylaxis 95 

Vaughan's    Theory 9(5 

Tolerance  of  Alien  Proteins 97 

Clinical  Symptoms  Attributable  to  Protein  Sensitization  or  Anaphylaxis  9^ 

The  Relative  Importance  of  Anaphylaxis  as  a  Cause  of  Systemic  Disorder  9s 

Anaphylaxis  as  a  Cause  of  Functional  Disorder 99 

Symptoms   Frequently  Believed  by  the  Removal   of   Sources  of   Chronic 

Intoxication !•'.> 

General   symptoms 99 

Diseases   of   the   skin 100 

Functional    disorders   and    neuroses 100 

Disorders  of  the  vegetative  nervous  system 100 

Functional  disturbance  due  in  part  to  organic  disease 100 

Symptoms   due   in   part   to   other   infections 100 

CHAPTER  VII 

HEADACHE  AS  BELATED  TO  ORAL  SEPSIS 

Oral   Sepsis  as  a  Primary  and  as  a  Contributing  Cause  of  Headache     .  102 

Oral   Sepsis  as  a   Source  of  Arthritis  in  Cervical  Spine,  etc 102 

Oral  Sepsis  as  a  Source  of  Neuralgia  or  Neuritis  in  Facial  Nerve     .     .  104 

Headache  as  a  Referred  Pain  from  a  Diseased  Tooth 104 

Headache  Caused  by  Antrum  Infection  Due  Primarily  to  Oral  Sepsis     .  105 

CHAPTER  VIII 

SUMMARY  AND  CONCLUSIONS 

Frequent  Occurrence  of  Oral  Sepsis 106 

Statistics  Showing  the  Comparison  Between  the  Occurrence  of  Oral 

Sepsis  and  That  of  Other  Chronic  Infections 106 

Limitation  of  Conclusions  Drawn  from  Clinical  Observations  ....  107 
Statistics  Showing  the  Frequency  with  which  Oral  Sepsis  and  Other 

Chronic  Infections  Coexist 107 

Conclusions  Concerning  the  Importance  of  Oral  Sepsis  as  a  Cause  of 

Systemic  Disorder 109 

Conclusions  Concerning  the  Various  Ways  in  Which  Oral  Sepsis  May 

Cause  III  Health 109 

Results  Which  Follow  the  Eradication  of  Oral  Sepsis 109 

Treatment  of  Oral  Sepsis 110 


ILLUSTRATIONS 


FIG.  PAGE 

1-4.       Illustrations  showing  a  normal  condition  of  roots  and  alveolar 

process 25 

5-6       Illustrations   showing   erosion   of    alveolar   process 26 

7-10.     Case  of  pyorrhea  alveolaris  of  long  standing 27 

11-14.  Illustrations  of  cases  in  which  the  alveolar  process  has  been  so 
destroyed  by  infection  that  some  of  the  teeth  are  held  in 

place  by  soft  tissues  alone 28 

15-10.  Pyorrheal   abscesses 29 

17.        Abscess  at  the  root  apex  of  a  vital  tooth 29 

18-21.  Showing  ill  effect  upon  the  alveolar  process  of  careless  dental 

work 30 

22-24.  Showing   the   ill   effect    upon    the    alveolar    process   of    careless 

dental    work 31 

2;"5-."»0.  Illustrations  showing  deposits  on  necks  of  roots 33 

31-36.  Case   of   chronic   recurrent   pyorrhea    alveolaris 35 

37-41.  Illustrations  of  large  alveolar  abscesses 38 

42-43.  Osteomyelitis    of    the    jaw    derived    from    an    infection    at    the 

roots   of   a   molar   tooth 39 

44-49.  Illustration  of  the  less  active  type  of  pcriapical  infection     .     .     40 
50-55.  Typical  example  of  oral  sepsis  in  a  patient  with  a  great  deal 

of   dental   work 41 

56-50.  Example  of  the  occurrence  of  numerous  large  abscesses     ...     42 
60-65.  Example  of  an  individual  having  a  great  deal  of  dental  work, 

who  shows  relatively  little  periapical  sepsis 43 

66-71.  Illustration   of   the   commonest   source   of   periapical    infection; 
namely,    devitalized    teeth    with    incompletely    filled    root 

canals 44 

72-74.  Illustration  of  abscesses  due  to  perforation  of  root  by  pins     .     .     45 

75-77.  Apical  sepsis  due  to  infection  of  the  pulp  by  decay 46 

78-83.  Examples  of  root  remnants  which  arc  the  site  of  infection     .     .     47 
84-89.  Examples  of  infection  at  the  apices  of  filled  teeth  whose  pulp 

was   not   intentionally   destroyed 48 

90-91.  Examples  of  infection  at  the  root  apices  of  unerupted  teeth     .     49 
92.        Example  of  periapical   infection   of   teeth  whose   pulp  was   de- 
stroyed   by    severe    trauma 50 

93-97.  Example  of  periapical  infections  of  crowned  teeth  whose  pulp 

was  not  purposely  devitalized 51 

98-99.  Examples  of  periapical  infection  of  untreated  teeth     ....     52 

13 


14  ILLUSTRATION'S 

/ 

llV[G.  PACK 

100-102.  Absorption   of   the   tips   of   the   root   apices   and   necrosis   of 

the  apex 5.", 

IO.'5-l  00.  Several  teeth  showing  one  or  more  completely  necrosed  roots     54 
107-11.°).  Illustrations  of  shadows  indicating  areas  of  increased  density 
in  the  alveolar  process  as  a  result  of  healing  of  infected 
areas 55 

114-11(5.  Illustrations   of  radiopaque  areas   which  simulate  the   healed 

abscesses  shown  in  Figs.  107-113 50 

117.  Eoentgenogram  showing  bone  of  increased  density 57 

118-120.  Examples   of    root    remnants   which   have   apparently   become 

encysted 57 

121.  Roentgenogram   taken  immediately  after  drainage   and  filling  of 

the   root   canal 00 

122.  Roentgenogram  of  the  same  tooth  as  in  Fig.   121  approximately 

one   year   later (50 

12)!.  Roentgenogram    taken    just    before    drainage    and    filling   of    the 

root  canal 00 

124.  Roentgenogram  of  the  same  tooth  as  in  Fig.  123  two  months  later     (•() 

125.  Roentgenogram  showing  small  area  of  apical  sepsis (51 

120.  Roentgenogram   of   same   tooth   taken   approximately   six   months 

after   its    treatment 01 

127.  Roentgenogram   showing  small   area  of   sepsis 01 

128.  Roentgenogram  showing  same  tooth   approximately  three  months 

after    its    treatment (51 

129.  Roentgenogram  showing  apical  infection 02 

130.  Roentgenogram  taken  shortly  after  the  filling  of  the  root  canal     .  02 

131.  Roentgenogram  taken  approximately  eight  months  after  that  shown 

in    Fig.    130 02 

1  .'12.  Roentgenogram  showing  an  abscess  at  the  root  of  a  crowned  left 

upper  incisor 03 

!.'!.">.  Roentgenogram  taken  three  months  after  irrigation  through  the 
root  canal  of  the  left  incisor  followed  by  filling  of  the  root 

canal 03 

1  )!4.  Roentgenogram  taken  six  months  after  treatment (>•"> 

1.">5.  Roentgenogram  showing  apical  infection  at  the  root  of  a  lower 

molar   tooth 04 

1  .'!(>.  Roentgenogram    taken   approximately   six   months   after   drainage 

and  filling  of  the  root  canal 04 

1. '57-135).  Roentgenograms  showing  sepsis  at  the  apices  of  two  lower 

molar  teeth  before,  during,  and  after  treatment     ...     04 
140-142.  Roentgenograms   showing   large   alveolar   abscess   before   and 

after   treatment 05 

143-14(5.  Roentgenograms  showing  abscesses  at  the  roots  of  two  lower 

incisor  teeth  before,  during,  and  after  treatment     ...     65 


ILLUSTRATIONS  15 

FIG.  PAGE 

147-148.  Roentgenograms  showing  large  discharging  alveolar  abscess  at 
the  apex  of  a  lower  incisor  tooth  before  and  after  treat- 
ment   66 

149-150.  Roentgenograms  showing  an  abscess  at  the  root  of  an  upper 

bicuspid  tooth  before  and  after  treatment 66 

151-152.  Roentgenograms  showing  an  abscessed  lower  molar  tooth  lie- 
fore  and  after  treatment 66 

153-161.  Examples  of  careful  root  canal  work 67-70 

162.  Case  of  chronic  migratory  polyarthritis  of  several  months'  dura- 

tion  which   was   completely   relieved   by   extraction   of   tooth 
shown  in  illustration 76 

163.  Case  of  multiple  neuritis  relieved  by  extraction  of  tooth     ...     76 

164.  Case    of   recurrent   pain   in   gall   bladder   region    associated   with 

jaundice  relieved  by  extraction  of  tooth 76 

1(55.  Case  of   staphylococcus   septicemia 80 

166-167.  Roentgenograms  showing  broaches  which  had  been  introduced 
with  ease  through  the  root  canal  and  alveolar  process 
practically  as  far  down  as  the  dental  nerve 103 

168.  Case   of  severe  headache   due  to  cervical  arthritis  and  myostitis 

relieved  by  extraction  of  tooth 104 

169.  Case  of  severe  facial  neuralgia  relieved  by  extraction  of  a  tooth     .  104 

170.  Case  of  headache  due  to  antrum  infection,  the  source  of  which  was 

an  abscess  at  the  root  of  a  bicuspid  tooth 104 


ORAL  SEPSIS  IN  ITS  RELATIONSHIP 
TO  SYSTEMIC  DISEASE 


CHAPTER  I 
INTRODUCTION 

The  discovery  of  a  relationship  between  ill  health  and 
defective  teeth  is  by  no  means  recent.  It  has  received 
casual  mention  in  the  older  literature  and  has  been  in- 
dependently recognized,  perhaps  for  centuries,  by  prac- 
titioners of  medicine  and  dentistry.  The  subject  has  not 
received  the  prominence  it  deserves,  however,  previous 
to  the  past  decade.  We  wish  to  quote  in  toto  an  article 
published  by  Benjamin  Rush,  one  of  the  signers  of  the 
Declaration  of  Independence,  and  one  of  America's  most 
noted  physicians,  on  observations  commenced  by  him  in 
1801.  This  remarkable  article,  written  before  the  dis- 
covery of  bacteria  and  when  our  knowledge  of  pathology 
was  meager  indeed,  harmonises  in  its  essentials  with  the 
more  popular  views  of  the  present  day.  I  have  taken  the 
liberty  of  italicizing  several  striking  sentences. 

MEDICAL  INQUIRIES  AND  OBSERVATIONS* 
By  Benjamin  Rush,  M.D. 

Professor  of  the  Institute  and  Practice  of  Medicine  and  Clinical 
Practice  in  the  University  of  Pennsylvania 

*  *  Some  time  in  the  month  of  October,  1801,  I  attended 
Miss  A.  C.  with  rheumatism  in  her  hip  joint,  which 
yielded  for  a  while,  to  the  several  remedies  for  that  dis- 

*Vol.  I,  p.  199,  published  in  1818  bv  M.  Carey  &•  Son,  Philadelphia.  This  article 
was  found  by  Mrs.  Rose  M.  Hibbard  of  the  Kansas  City  Medical  Library  in  the  pri- 
vate collection  of  Dr.  A.  E.  Hertzler.  It  has  also  been  referred  to  by  George  N. 
Kreider,  A.  D.  Black,  and  David  Riesman. 

17 


18  ORAL   SEPSIS 

ease.  In  the  month  of  November  it  returned  with  great 
violence,  accompanied  with  a  severe  toothache.  Suspect- 
ing the  rheumatic  affection  was  excited  by  the  pain  in 
her  tooth,  which  was  decayed,  I  directed  it  to  be  ex- 
tracted. The  rheumatism  immediately  left  her  hip,  and 
she  recovered  in  a  few  days.  She  has  continued  ever 
since  to  be  free  from  it. 

"Soon  after  this  I  was  consulted  by  Mrs.  J.  R.  who 
had  been  affected  for  several  weeks  with  dyspepsia  and 
toothache.  Her  tooth,  though  no  mark  of  decay  appeared 
in  it,  was  drawn  by  my  advice.  The  next  day  she  was 
relieved  from  her  distressing  stomach  complaint,  and  has 
continued  ever  since  to  enjoy  good  health.  From  the 
soundness  of  the  external  part  of  the  tooth,  and,  the 
adjoining  gum,  there  was  no  reason  to  suspect  a  discharge 
of  matter  from  it  had  produced  the  disease  in  her  stomach. 

"Some  time  in  the  year  1801  I  was  consulted  by  the 
father  of  a  young  gentleman  in  Baltimore,  wiio  had  been 
affected  with  epilepsy.  I  inquired  into  the  state  of  his 
teeth,  and  was  informed  that  several  of  them  in  his  up- 
per jaw  were  decayed.  I  directed  them  to  be  extracted, 
and  advised  him  after  to  lose  a  few  ounces  of  blood,  at 
any  time  when  he  felt  the  premonitory  symptoms  of  a 
recurrence  of  his  fits.  He  followed  my  advice,  in  con- 
sequence of  which  I  had  lately  the  pleasure  of  hearing 
from  his  brother  that  he  was  perfectly  cured. 

"I  have  been  made  happy  by  discovering  that  I  have 
only  added  to  the  observations  of  other  physicians,  in 
pointing  out  a  connection  bettveen  the  extraction  of  de- 
cayed and  diseased  teeth  and  the  cure  of  general  diseases. 
Several  cases  of  efficacy  of  that  remedy  in  relieving  head- 
ache and  vertigo  are  mentioned  by  Dr.  Darwin.  Dr. 
Grater  relates  that  Mr.  Petit,  a  celebrated  French  surgeon, 
had  often  cured  intermitting  fevers,  which  had  resisted 
the  bark  for  months,  and  even  years,  by  this  prescrip- 
tion ;  and  he  quotes  from  his  works  two  cases,  the  one  of 


INTRODUCTION  19 

consumption,  the  other  of  vertigo,  both  of  long  continu- 
ance, which  were  suddenly  cured  by  the  extraction  of  two 
decayed  teeth  in  the  former,  and  of  two  supernumerary 
teeth  in  the  latter  case. 

"In  the  second  number  of  a  late  work,  entitled  Bib- 
liotheque  Germanique  Medico  Chirurgicale,  published 
in  Paris,  by  Dr.  Bluver  and  Dr.  Delaroche,  there  is  an 
account,  by  Dr.  Siebold,  of  a  young  woman  who  had  been 
affected  for  several  months  with  great  inflammation, 
pain,  and  ulcers,  in  her  right  upper  and  lower  jaws,  at 
the  usual  time  of  the  appearance  of  the  catamenia,  which 
at  that  period  were  always  deficient  in  quantity.  Upon 
inspecting  the  seat  of  those  morbid  affections,  the  doctor 
discovered  several  of  the  molars  in  both  jaws  to  be  de- 
cayed. He  directed  them  to  be  drawn,  in  consequence 
of  which  the  woman  was  relieved  of  the  monthly  disease 
in  her  mouth,  and  afterwards  had  a  regular  discharge  of 
her  catamenia. 

"These  facts,  though  but  little  attended  to,  should  not 
surprise  us,  when  we  recollect  how  often  the  most  dis- 
tressing general  diseases  are  brought  on  by  very  incon- 
siderable inlets  of  morbid  excitement  into  the  system. 
A  small  tumor,  concealed  in  the  fleshy  part  of  the  leg, 
has  been  known  to  bring  on  epilepsy.  A  trifling  w^ound 
with  a  splinter  or  a  nail,  even  after  it  has  healed,  has 
often  produced  a  fatal  tetanus.  Worms  in  the  bowels 
have  produced  internal  dropsy  of  the  brain,  and  a  stone 
in  the  kidney  has  excited  the  most  violent  commotions  in 
every  part  of  the  system.  Many  hundred  facts  of  a  simi- 
lar nature  are  to  be  met  with  in  the  records  of  medicine. 

"When  w.e  consider  how  often  the  teeth,  ivhen  decayed, 
are  exposed  to  irritation  from  hot  and  cold  drinks  and 
aliments,  from  pressure  by  mastication,  and  from  the 
cold  air,  and  hoiv  intimate  the  connection  of  the  mouth 
is  ivith  the  whole  system,  I  am  disposed  to  believe  they 
are  often  the  unsuspected  causes  of  general,  and,  par- 


20  OKAL   SEPSIS 

ticularly  of  nervous  diseases.  When  we  add  to  the  list 
of  those  diseases  the  morbid  effects  of  the  acrid  and 
putrid  matters,  which  are  sometimes  discharged  from 
the  carious  teeth,  or  from  the  ulcers  in  the  gums  created 
by  them,  also  the  influence  which  both  have  in  prevent- 
ing perfect  mastication,  and  the  connection  of  that  ani- 
mal function  with  good  health,  /  can  not  lielp  think  hit/ 
that  our  success  in  the  treatment  of  all  chronic  diseases 
irould  be  very  much  promoted,  by  directing  our  inquiries 
into  the  state  of  the  teeth  in  sick  people,  and  by  a<lri*'ni<i 
their  extraction  in  every  case  in  which  they  are  decayed. 
It  is  not  necessary  that  they  should  be  attended  with  pain, 
in  order  to  produce  diseases,  for  splinters,  tumors,  and 
other  irritants  before  mentioned,  often  bring  on  dis- 
ease and  death,  when  they  give  no  pain,  and  are  unsus- 
pected causes  of  them.  This  translation  of  sensation 
and  motion  into  parts  remote  from  the  place  where  im- 
pressions are  made,  appears  in  many  instances,  and 
seems  to  depend  upon  an  original  law  of  the  animal 
economy. ' ' 


The  following  generalizations  are  recognized  by  many 
who  have  interested  themselves  in  the  bearing  which  the 
teeth  have  upon  health.  Very  few  men  of  fifty  years  or 
over  who  show  advanced  stages  of  dental  sepsis  are  nor- 
mal physically.  The  vast  majority  have  chronic  disease. 
There  are,  of  course,  notable  exceptions  to  this.  Con- 
versely, adults  of  fifty  or  over  who  have  perfect  teeth 
free  from  sepsis  are  often  remarkably  free  from  chronic 
disease  (inflammatory  in  origin)  and  are  usually  well 
preserved.  Striking  examples  of  individuals  seventy  to 
ninety  years  of  age  with  nearly  perfect  teeth  and  splen- 
did health  impress  one  with  the  reality  of  a  relationship 
between  the  two.  Men  of  advanced  age  who  have  worn 
false  teeth  for  a  number  of  years  have  better  health  as 


INTRODUCTION  21 

a  rule  than  the  average  of  their  age  who  have  retained 
defective  teeth. 

In  earlier  years  the  relationship  between  ill  health  and 
defective  teeth  was  attributed  to  caries.  It  was  very  ap- 
parent that  this  rendered  teeth  unfit  for  mastication  and 
that  the  lack  of  this  function  might  be  a  source  of  diges- 
tive disturbance.  Infection  of  food  by  carious  teeth  dur- 
ing the  process  of  chewing  seemed  a  factor  as  also  did 
the  swallowing  of  putrid  matter  from  carious  teeth  and 
of  pus  from  infected  gums. 

It  is  not  unlikely  that  the  swallowing  of  poorly  masti- 
cated food,  the  swallowing  of  pus,  putrid  material,  etc., 
lias  some  slight  untoward  influence  upon  digestion.  It 
does  not  seem  probable,  however,  that  it  has  an  impor- 
tant bearing  upon  the  many  systemic  ills  for  which  the 
teeth  are  now  thought  to  be  remotely  responsible.  The 
fact  is  that  the  mucous  membrane  of  the  gastrointestinal 
tract  when  in  healthy  condition  can  tolerate  a  great  deal 
of  abuse.  It  can  tolerate  poorly  masticated  food,  and, 
as  a  rule,  can  destroy  septic  material  when  swallowed. 
The  serious  effect  of  oral  sepsis  is  rarely  through  this 
channel  in  individuals  who  are  otherwise  normal. 

Pyorrhea  is  mentioned  as  a  possible  factor  in  the  etiol- 
ogy of  anemias,  joint  troubles,  etc.,  in  some  of  the  older 
textbooks.  Its  importance,  however,  as  a  frequent  source 
of  chronic  infection  distributed  by  the  blood  to  remote 
organs  is  a  recent  suggestion.  The  discovery  of  the  fre- 
quency of  alveolar  abscesses  and  granulomata  and  their 
importance  as  a  source  of  ill  health  is  of  still  more  re- 
cent date  and  has  been  brought  to  light  through  dental 
roentgenology.  The  fact  that  alveolar  abscesses  are  of 
greater  pathologic  import,  so  far  as  general  health  is 
concerned,  than  pyorrhea  seems  at  once  evident.  Alveo- 
lar abscesses  lack  drainage.  In  pyorrhea  drainage  is 
often  good.  Not  only  are  alveolar  abscesses  blind,  but 
their  localization  in  bony  tissue  renders  them  a  more 


22  ORAL   SEPSIS 

serious  detriment  to  health  than  septic  foci  of  equal  size 
in  soft  tissues  such  as  the  gums  where  expansion  is  pos- 
sible. Apical  sepsis  would  appear  a  greater  factor  than 
pyorrhea  in  the  causation  of  disease  for  another  impor- 
tant reason;  namely,  pyorrhea  gives  rise  to  symptoms 
which  usually  attract  the  attention  of  both  patient  and 
dentist.  Alveolar  abscesses  do  not  give  rise,  as  a  rule, 
to  a  single  disagreeable  symptom  by  which  either  pa- 
tient or  dentist  is  led  to  suspect  their  existence.  Conse- 
quently, many  individuals  have  been  subject  to  the  effect 
of  sepsis  in  the  alveolar  process  for  years  even  though 
they  have  paid  scrupulous  attention  to  their  teeth  and 
visited  the  dentist  frequently.  The  frequent  failure  of 
alveolar  abscesses  to  cause  pain  or  other  local  evidence 
of  trouble  often  makes  it  difficult  to  convince  patients 
that  their  teeth  need  attention;  in  fact,  dentists  them- 
selves occasionally  refuse  to  believe  that  certain  teeth 
are  diseased,  even  when  the  fact  can  be  clearly  demon- 
strated in  dental  roentgenograms.  This  frequently  leads 
to  controversies  and  unfortunate  situations. 

The  incidence  of  infection  in  the  gums  and  alveolar 
process  is  astonishingly  great.  It  is  not  frequently  found 
in  individuals  of  less  than  twenty  years,  but  is  found  in 
the  vast  majority  of  adults.  It  is  found  oftener  and  in 
greater  extent  as  age  advances,  and  in  late  adult  life 
few  escape  it  entirely. 

One  of  the  greatest  sources  of  dental  sepsis  aside  from 
decay,  tartar,  and  gross  neglect,  is  dental  work.  It  is 
not  altogether  fair  to  the  dentists  to  say  defective  den- 
tal work,  for  the  same  is  very  frequently  true  even  of 
dental  work  carried  out  according  to  the  more  approved 
methods  of  the  past  decade.  As  a  broad,  general  rule 
it  can  be  said  of  individuals  whose  teeth  have  received 
careful  attention  that  the  amount  of  oral  sepsis  at  a 
given  age  varies  largely  with  the  amount  of  dental  work 
and  that  few  individuals  with  a  considerable  amount  of 


INTRODUCTION"  23 

dental  work  are  free  from  it.  It  is  generally  stated  by 
dentists  who  have  interested  themselves  in  the  septic  con- 
ditions of  the  mouth  that  fifty  per  cent  or  more  of  de- 
vitalized teeth  show  roentgen  shadows  at  the  root  apices 
which  are  indicative  of  chronic  sepsis  and  that  a  very 
large  proportion  of  crowns,  fillings,  and  bridges  project 
at  the  gum  margin  enough  to  irritate  the  gum  and  leave 
pockets  in  wrhich  food  material  can  lodge  and  putrify  and 
lead  almost  inevitably  to  pyorrhea. 

Dentists  have  been  wonderfully  successful  in  preserv- 
ing the  visible  portion  of  the  teeth  and  in  making  restora- 
tions which  look  well  and  serve  well  for  purposes  of 
mastication,  but  very  fewr  have  given  the^attention  to  sep- 
sis which  it  now  appears  to  deserve.  'Fillings,  crowns, 
and  bridges  have  not  been  constructed  in  the  past  with 
a  paramount  purpose  of  avoiding  sepsis,  and  have  often 
been  attached  to  teeth  so  badly  infected  that  a  sanitary 
result  could  not  have  been  hoped  for.  The  sins  of  com- 
mission have  been  no  greater  than  the  sins  of  omission, 
for  many  of  the  most  skilled  dentists  even  at  the  present 
day  allow  patients  to  leave  their  offices  looking  lightly 
upon  a  degree  of  sepsis  which  may  be  not  only  detrimen- 
tal to  their  physical  welfare,  but  may  also  lead  eventually 
to  the  loss  of  more  teeth.  In  mentioning  this,  we  do  not 
wish  to  question  the  skill  of  dentists,  but  rather  to  em- 
phasize the  fact  that  unanimity  of  opinion  between  phy- 
sicians and  dentists  concerning^Oie  diagnosis  of  dental 
sepsis  and  concerning  the  remote  effect  of  the  same  is 
urgently  needed,  as  is  also  hearty  cooperation  in  its  treat- 
ment. In  the  past  the  practice  of  dentistry  has  been 
directed  toward  the  preservation  of  the  teeth  almost 
solely  for  mechanical  and  cosmetic  purposes.  In  the 
future  it  appears,  it  is  destined  to  have  as  one  of  its 
chief  aims  the  prevention  and  cure  of  disease. 


CHAPTER  II 
PYORKHEA  ALVEOLARIS 

Pyorrhea  alveolaris  is  rarely  due  to  one  cause  alone. 
In  an  overwhelming  majority  of  cases  it  is  due  to  one 
chief  cause  and  several  important  contributing  causes. 
The  more  important  causes  are  mechanical  conditions 
which  expose  the  gums  repeatedly  to  injury  or  to  the  ir- 
ritating effects  of  putrefying  food  material,  secretions, 
etc. ;  systemic  or  local  conditions  which  increase  the  sus- 
ceptibility of  the  gums  to  infection  and  finally  infection 
itself.  The  successful  treatment  of  pyorrhea  depends 
upon  the  removal  of  each  abnormal  condition  which  takes 
part  in  its  etiology. 

Causes  of  Pyorrhea  Alveolaris 

1.  Microorganisms;  streptococcus  group,  pneumococ- 
cus    group,    staphylococcus   group,   amebse,    spirochetse, 
and  fusiform  bacilli  of  Vincent's  angina,  bacilli  of  many 
types,  putrefactive  organisms,  etc. 

2.  Chronic  irritation  or  trauma,  such  as  that  caused 
by  tartar,  decay,  malocclusion,  defective  dental  work, 
and,  perhaps,  in  rare  instances,  by  the  improper  use  of 
toothpicks,  toothbrushes,  etc. 

3.  Unsanitary  conditions,  such  as  may  be  caused  by 
pockets  and  irregularities  of  the  teeth  which  make  pos- 
sible the  lodgement  and  putrefaction  of  secretions,  food 
materials,  etc.    Such  may  occur  as  a  result  of  defective 
dental  work,  tartar,  decay,  irregularity  of  the  teeth,  etc. 

4.  Conditions  which  prevent  the  normal  massage  of  the 
gums  and  cleaning  of  the  teeth  by  the  excursion  of  food, 
the  tongue,  and  cheeks  during  the  process  of  mastication ; 

24 


PYORRHEA   ALVEOLARIS 


25 


namely,  malocclusion,  irregularity  of  the  teeth,  and  de- 
fective dental  work. 

5.  Constitutional  conditions  which  increase  the  sus- 
ceptibility of  the  gums  to  infection;  namely,  diabetes, 
pregnancy,  lactation,  alcoholism,  lead  poisoning,  the  use 
of  mercury  and  potassium  iodide  in  therapy,  chronic  de- 
bilitating diseases,  blood  diseases,  anemia,  etc.,  diseases 
of  the  ductless  glands,  scurvy,  acute  infectious  diseases. 


Fig.   1. 


Fig.  2. 


Fig.  3. 


Fig.  4. 


Figs.    1-4. — Illustrations    showing    a    normal    condition    of    roots    and    alveolar    process. 
Figs.  1  and  2,  in  adult  life.     Figs.  3  and  4,  before  eruption  of  second  teeth. 

chronic  infections,  such  as  infected  tonsils,  alveolar  ab- 
scesses, infected  nasal  sinuses,  chronic  appendicitis, 
cholecystitis,  etc. 

The  above  factors  vary  in  their  relative  importance, 
and  each  factor  varies  in  its  degree  of  importance.  Sev- 
eral factors  play  a  part  in  the  majority  of  cases.  When 
this  is  the  case,  relatively  unimportant  factors  may  play 
important  roles.  For  example,  acute  trauma,  such  as 


26 


ORAL   SEPSIS 


that  brought  about  by  injury  or  by  the  use  of  toothpicks, 
stiff  toothbrushes,  etc.,  seldom  or  never  causes  pyorrhea 
in  normal  individuals  with  normal  teeth,  in  fact,  stiff 
brushes  are  used  in  prophylaxis  against  pyorrhea.  In  a 
patient  with  diabetes,  however,  or  in  pregnant  women, 
acute  trauma  may  initiate  an  infection  of  the  gums,  espe- 
cially if,  in  addition  to  this,  the  patient  has  tartar  or  de- 
fective dental  work.  Likewise,  the  irritating  effect  of 
defective  dental  work  which  might  be  well  tolerated  by  a 
normal  individual  might  be  a  source  of  severe  pyorrhea 
in  an  individual  taking  intensive  "doses  of  mercury  or 
potassium  iodide,  or  in  an  individual  with  irregular  teeth 
having  accumulations  of  tartar,  etc. 


Fig.  6. 

Figs.    5    and    6. — Illustration    showing    erosion    of    the    alveolar    process    (moderate    in 
degree)    due   to    chronic    infection   derived    from    the   gum    margin. 

As  previously  mentioned,  the  majority  of  individuals 
Avith  pyorrhea  show  the  presence  of  two  or  more  causa- 
tive factors.  Unfortunately,  in  many  instances,  numer- 
ous factors  can  be  found.  The  reason  for  this  becomes 
apparent  if  the  causative  factors  are  traced  to  their 
sources  of  origin.  For  example,  enlarged  tonsils  and 
adenoids  are  common  causes  of  mouth-breathing  in  chil- 
dren. Mouth-breathing  is  a  common  cause  of  malocclu- 
sion  and  irregularity  of  the  teeth.  Malocclusion  inter- 
feres with  the  self-cleansing  of  the  teeth,  prevents  the 
normal  massage  of  the  gums,  and  allows  the  accumula- 
tion of  tartar.  The  unsanitary  conditions  caused  there- 


PYORRHEA    ALVEOLARIS 


27 


by  predispose  to  decay  and  make  dental  work  necessary. 
Decay,  tartar,  and  dental  work  are  the  most  frequent 
causes  of  pyorrhea.  Individuals  who  have  been  mouth- 
breathers  by  reason  of  hypertrophied  tonsils  and  ad- 
enoids are  likely,  therefore,  to  have,  not  only  defective 
teeth  which  are  prone  to  cause  pyorrhea,  but  also  hyper- 
trophied infected  tonsils  which  may  lower  resistance  to 
infection  and  which  in  this  way  increase  the  susceptibility 


Fig.   7. 


Fig.  9. 


Fig.  10. 


Figs.  7-10. — Case  of  pyorrhea  alveolaris  of  long  standing.     Shows  great  destruction  of 

the  alveolar  process. 

of  the  gums  to  infection.  Such  individuals  are  also  likely 
to  have  one  or  more  systemic  diseases  as  a  result  of  acute 
or  chronic  tonsillitis,  which  may  cause  an  additional  low- 
ering of  resistance.  All  of  the  above  factors  singly  or 
combined  may  play  important  parts  in  the  pathogenesis 
of  pyorrhea.  In  the  average  medical  case,  not  one,  but 
several  predisposing  factors  can  usually  be  found. 
Infection  is  seldom  or  never  a  sole  cause  of  pyorrhea. 


28 


ORAL   SEPSIS 


Pyorrhea  would  seem  theoretically  impossible,  however, 
without  infection  as  a  primary  cause.  Maloccmsion,  de- 
fective dental  work,  etc.,  might  cause  pressure  atrophy 
of  the  gum  and  alveolar  process,  but  could  never  cause 
the  chronic  inflammatory  changes  of  pyorrhea  unless  in- 
fection were  superimposed. 

The  microorganisms  found  in  septic  pockets  about  the 


Fig.   11. 


Fig.   12. 


Fig.   13. 


Fig.   14. 


Figs.  11-14. — Illustrations  of  cases  in  which  the  alveolar  process  has  been  so 
destroyed  by  infection  that  some  of  the  teeth  are  held  in  place  by  soft  tissues  alone. 
Pressure  on  such  teeth  during  mastication  forces  them  down  on  cushions  of  chronically 
infected  tissue.  They  would  appear  a  greater  menace  to  health  than  infected  teeth 
whose  roots  are  still  embedded  in  bone  and  held  in  place  more  firmly.  The  teeth 
shown  in  Figs.  13  and  14  had  been  treated  for  two  years  by  a  pyorrhea  specialist. 
The  surface  of  the  gum  was  pink  and  appeared  relatively  healthy.  Marked  relief  of 
svstemic  complaint  followed  the  extraction  of  teeth  in  each  of  the  cases  illustrated 
above. 

teeth  are  numerous  and  varied.  If  the  superficial  pus 
in  pyorrhea  pockets  is  removed  and  examined,  a  great 
variety  are  found  coexisting ;  namely,  streptococci,  pneu- 
mococci,  diplococci,  staphylococci,  bacilli,  spirochetes,  and 
amebse,  of  various  sizes  and  strains.  If  the  superficial 


PYORRHEA    ALVEOLARIS 


29 


pus  is  wiped  away  and  a  culture  or  smear  is  taken  from 
the  deeper  areas,  the  members  of  the  streptococcus  and 
staphylococcus  group  are  found  most  constantly.  Strep- 
tococci usually  predominate  in  numbers  and  are  often  in 
relatively  pure  culture.  Streptococcus  viridans,  strepto- 
coccus hemolyticus,  and  amebse  can  be  demonstrated  in 


Fig.   15. 


Fig.  16. 


Figs.    15-16. — Pyorrheal  abscesses.      These  teeth   are   held   more   firmly  in  place  by   the 
remains  of  the  alveolar  process  than  those   shown  in  illustrations   11   to   14. 


Fig.    17. 

Fig.  17. — Abscess  at  the  root  apex  of  a  vital  tooth.  Tooth  responded  to  all  tests 
for  vitality  of  pulp.  The  infection  was  derived  from  the  gum  margin.  The  anterior 
table  of  the  alveolar  process  had  been  eroded  as  far  down  as  the  apex  of  the  root. 
The  gum,  however,  appeared  relatively  healthy  on  casual  examination.  The  tooth 
had  never  caused  pain  or  other  symptoms  which  had  attracted  the  attention  of  the 
patient. 

almost  every  case,  and  a  few  colonies  of  staphylococcus 
aureus  and  albus  in  the  majority  of  cases. 

It  seems  improbable  that  any  individual  organism 
plays  a  specific  role  in  the  pathology  of  the  disease. 
Many  of  the  organisms  which  can  be  isolated  are  patho- 
genic and  capable  of  causing  acute  or  chronic  inflam- 
matory change  in  many  tissues  under  favorable  con- 
ditions. One  doubts,  however,  if  any  of  them  ever  gain 


30 


ORAL   SEPSIS 


a  foothold  in  the  tissues  of  a  normal  healthy  gum,  and 
cause  local  disease  unless  the  resistance  of  the  gum 
against  infection  is  lowered  by  some  coexisting  abnormal 
condition.  In  fact,  one  might  be  justified  in  believing 
that  if  a  pure  culture  of  bacteria  obtained  from  a  ease 
of  pyorrhea  were  applied  directly  to  the  gum,  the  bac- 
teria would  probably  be  washed  away  and  killed  by  the 
secretions  of  the  mouth,  and  do  no  harm  unless  tho  gum 


* 


Fig.   18. 


Fig.  19. 


Fig.  20.  Fig.  21. 

Figs.  18-21. — Illustrate    the  ill  effect  upon  the  alveolar  process  of  careless  dental  work. 

had  been  previously  rendered  susceptible  to  attack  by 
local  injury,  lowered  resistance,  or  both  combined. 

A  spirillum  associated  with  a  fusiform  bacillus  found 
in  great  numbers  in  Vincent's  angina  is  perhaps  worthy 
of  special  mention.  These  organisms  are  found  in  small 
numbers  in  pus  expressed  from  pockets  about  the  teeth 
and  tonsils  in  normal  individuals.  They  are  occasionally 
found  in  overwhelming  numbers  and  in  almost  pure  cul- 
ture in  cases  of  severe  rapidly  advancing  pyorrhea.  This 


PYOKRHEA    ALVEOLARIS 


31 


type  of  disease  may  progress  with  great  rapidity,  and 
may  cause  rapid  destruction  of  the  soft  parts  and  alveo- 
lar process  even  in  patients  with  relatively  normal  teeth 
and  gums.  It  is  more  commonly  observed,  however,  in 
individuals  in  whom  irregularity  of  teeth,  tartar,  defec- 
tive dental  work,  or  careless  habits  render  the  mouth 
unsanitary.  This  disease  usually  yields  rapidly  to  local 
treatment. 


Fig.   22. 


Fig.  23. 


Fig.  24. 
Figs.  22-24. — Illustrate  the  ill  effect  upon  the  alveolar  process  of  careless  dental  work. 

The  presence  of  ameb<e  can  be  demonstrated  in  the 
vast  majority  of  chronic  lesions  of  the  gum.  They  are 
often  present  in  great  number,  especially  in  the  deeper 
pockets.  This  discovery  led  Bass  and  Johns  to  suggest 
the  use  of  emetine  in  the  treatment  of  pyorrhea.  It  is 
difficult  to  determine  whether  or  not  amebae  play  an  im- 
portant role  in  the  pathology  of  pyorrhea  or  whether  they 
are  harmless  secondary  invaders.  It  appears  true,  how- 
ever, that  emetine  has  a  certain  limited  sphere  of  useful- 


32  ORAL   SEPSIS 

ness  in  therapy.  Its  effect  is  not  permanent,  however, 
unless  the  mechanical  and  sanitary  condition  of  the 
mouth  is  properly  cared  for. 

Temporary  trauma,  such  as  might  be  caused  by  an  acute 
injury  or  by  the  use  of  toothpicks  or  toothbrushes  and 
by  the  irritating  effects  of  tobacco,  is  perhaps  never  in 
itself  a  cause  of  pyorrhea  in  healthy  individuals  with 
regular,  clean  teeth.  Temporary  trauma  may  be  a  con- 
tributing cause  of  minor  importance,  however,  in  patients 
with  unsanitary  oral  cavities. 

Chronic  irritation  and  repeated  trauma  of  the  gum, 
and  unsanitary  conditions  due  to  tartar,  decay  at  the 
gum  margin,  poorly  constructed  fillings,  crowns  and 
bridges,  malocclusion,  irregularity  of  the  teeth,  etc.,  are 
among  the  most  important  and  most  frequently  observed 
causes  of  pyorrhea  alveolaris.  If  teeth  were  all  regular 
and  kept  clean,  and  if  dental  work  was  always  properly 
constructed,  pyorrhea  would  be  a  relatively  rare  disease. 

Pyorrhea  due  to  the  above  causes  is  likely  to  occur  in 
localized  areas  of  infection  at  first.  It  is  found  fre- 
quently under  defective  fillings,  crowns  and  bridges,  and 
in  such  locations  there  may  be  extensive  destruction  of 
both  gum  and  alveolar  process.  Later  the  infection  is 
likely  to  become  more  general.  It  hardly  comes  within 
the  scope  of  a  medical  man  to  say  more  concerning  this 
purely  dental  problem. 

Loivered  resistance  to  infection  has  an  important  bear- 
ing upon  the  development  of  pyorrhea.  Dentists  who 
neglect  this  factor  are  likely  to  have  a  number  of  failures 
in  their  efforts  to  cure  pyorrhea.  Eesistance  may  be 
lowered  by  the  following  diseases  to  such  an  extent  as 
to  render  the  gums  abnormally  susceptible  to  infection: 

First,  by  constitutional  conditions,  such  as  diabetes, 
pregnancy,  lactation,  alcoholism,  debilitating  diseases, 
blood  diseases,  anemia,  diseases  of  the  ductless  glands, 
lead  poisoning,  and  scurvy,  and  by  the  therapeutic  use 


PYORRHEA    ALVEOLARIS 


33 


of  mercury  and  potassium  iodide.  It  is  well  known  that 
pyorrhea  frequently  starts  and  advances  rapidly  during 
pregnancy  and  lactation,  especially  in  individuals  with 


Fig.  25. 


Fig.  26. 


Fig.  27. 


Fig.  28. 


Fig.  29. 


Fig.  30. 


Figs.  25-30. — Illustrations  show  deposits  on  necks  of  roots.  In  some  instances  there 
appears  to  ne  bone  proliferation  of  the  root  due  to  chronic  irritation  of  the  peridental 
membrane  just  below  the  gum  margin. 

defective  and  unsanitary  oral  cavities;  also  that  pyor- 
rheal  sepsis,  like  other  forms  of  sepsis,  is  likely  to  occur 


34  ORAL   SEPSIS 

in  patients  with  diabetes,  anemia,  etc.  The  reason  is  that 
the  defensive  mechanism  in  patients  with  these  condi- 
tions is  definitely  reduced  in  its  power  to  combat  infec- 
tion so  that  they  become  fit  subjects  for  pneumonia, 
tuberculosis,  furunculosis,  pyorrhea,  and  other  infec- 
tions. Such  patients  may  combat  infection  normally  it' 
the  systemic  condition  is  relieved.  A  case  of  acute  super- 
ficial pyorrhea  observed  in  a  patient  with  diabetes  who 
had  regular,  normal  teeth,  cleared  up  without  local  treat- 
ment a  few  days  after  the  urine  was  rendered  free  from 
sugar. 

Second,  resistance  against  infection  may  be  lowered 
by  infection.  It  may  be  lowered  by  the  more  localized 
infections,  such  as  tonsillitis,  alveolar  abscesses,  infected 
nasal  sinuses,  cholecystitis,  appendicitis,  etc.,  and  by  the 
more  generalized  infections  such  as  typhoid*  fever.  The 
bearing  which  infection  in  distant  organs  may  have  upon 
the  development  and  course  of  pyorrhea  is  important  and 
often  striking.  Pyorrhea  is  sometimes  noticed  first  or 
apparently  cured  cases  recur  soon  after  an  attack  of 
tonsillitis,  or  after  the  development  of  an  acute  alveolar 
abscess,  or  after  a  sinus  or  gall-bladder  infection.  This 
is  especially  true  of  individuals  with  unsanitary  mouths. 
It  may  be  attributed  to -the  fact  that  resistance  is  low- 
ered by  the  acute  infection  to  such  an  extent  that  the 
organisms  about  the  teeth  flourish,  invade  the  tissue  of 
the  gum  and  cause  local  inflammation.  Analogous  ex- 
amples of  exacerbation  or  recurrence  of  apparently 
healed  inflammatory  processes  after  the  development  of 
acute  infections  are  commonly  met  with  in  the  practice 
of  medicine.  It  is  a  common  occurrence,  for  example, 
for  latent  tuberculosis  to  become  active  after  an  attack 
of  bronchitis  or  acute  tonsillitis.  Chronic  appendicitis, 
cholecystitis,  or  a  chronic  latent  Neisser  infection  may 
undergo  an  acute  exacerbation  during  or  following  acute 
bronchitis  or  tonsillitis.  Urethritis  that  has  been  clini- 


PYORRHEA   ALVEOLARIS 


35 


cally  well  for  months  has  been  known  to  recur  after  an 
attack  of  la  grippe.  A  healing  furuncle  may  discharge 
more  pus  or  the  scars  of  recently  healed  furuncles  may 


Fig.  31. 


Fig.  32. 


Fig.  33. 


Fig.  34. 


Fig.  35. 


Fig.  36. 


Figs.  31-36. — Case  of  chronic  recurrent  pyorrhea  alveolaris  in  a  patient,  age  70, 
with  remarkably  regular,  normal,  clean  teeth.  This  case  did  not  yield  well  to  treat- 
ment for  pyorrhea  until  after  the  extraction  of  the  abscessed  tooth  shown  in  Fig.  32. 
It  seemed  to  be  a  case  in  which  the  resistance  of  the  gum  against  infection  was 
lowered  by  the  undiscovered  untreated  abscessed  tooth.  The  systemic  condition  of 
the  patient  was  very  much  improved  after  the  extraction  of  the  abscessed  tooth  and 
the  condition  of  the  gum  was  kept  normal  thereafter  with  relatively  little  care. 

itch,  become  red  and  even  discharge  pus  after  the  de- 
velopment of  a  fresh  furuncle  or  after  an  attack  of  ton- 
sillitis. A  patient  we  observed  who  had  specific  disease 


36  ORAL   SEPSIS 

which  had  been  latent  for  four  years  had  an  extensive 
papillary  brown-red  rash  and  gave  a  positive  Wasser- 
mann  test  one  week  after  recovery  from  typhoid  fever. 
The  above  examples  are  mentioned  to  illustrate  the 
fact  that  resistance  against  infection  may  be  lowered  by 
infection.  It  may  be  lowered  either  by  focal  infections 
or  by  the  more  widespread  infections.  For  this  reason, 
alveolar  abscesses,  chronically  infected  tonsils  or  ade- 
noids, infected  nasal  sinuses,  chronic  appendicitis, 
chronic  cholecystitis,  and  other  chronic  infections  may 
be  insurmountable  obstacles  to  the  permanent  cure  of 
pyorrhea  by  local  treatment  alone.  The  gums  may  im- 
prove and  remain  healthy  so  long  as  the  teeth  are  kept 
scrupulously  clean  and  free  from  tartar,  but  so  soon  as 
the  hygiene  of  the  mouth  is  neglected  and  resistance  is 
lowered  by  fatigue,  exposure  to  cold,  indulgence  in  al- 
cohol, etc.,  increased  activity  of  some  chronic  infection 
may  cause  a  further  lowering  of  resistance  and  the 
lighting  up  of  a  latent  infection  of  the  gums.  Chronic 
foci  of  infection  are  frequently  contributing  causes  of 
pyorrhea  and  frequently  render  its  permanent  cure  dif- 
ficult. 


CHAPTER  III 
ALVEOLAR  ABSCESSES 

Alveolar  abscesses  have  two  sources  of  origin:  one 
through  infection  of  the  alveolar  process  from  the  root 
canal  of  teeth  with  infected  pulp;  the  other  through  in- 
fection from  the  gum  margin  after  pyorrheal  erosion  of 
the  alveolar  process.  The  former  type  of  abscess  is  the 
more  common. 

The  occurrence  of  alveolar  abscesses  is  astonishingly 
great.  Black  in  a  recent  article  reports  the  finding  of 
abscesses  at  the  roots  of  forty-seven  per  cent  of  de- 
vitalized teeth.  His  observations  were  made  on  indi- 
viduals without  reference  to  complaint  concerning  mouth 
conditions  or  state  of  health,  and  he  thinks  represents  the 
average  for  persons  of  less  than  forty  years  of  age.  In 
examining  one  thousand  medical  cases  in  office  practice 
on  whom  dental  films  were  made  as  a  routine  procedure, 
we  found  areas  of  bone  absorption  at  the  roots  of  eighty- 
one  per  cent  of  all  nonvital  teeth.  The  majority  of  the 
patients  were  over  forty  years  of  age. 

Considerable  variation  in  statistics  concerning  ab- 
scessed teeth  obtained  by  different  observers  can  be  ex- 
pected. The  relative  number  of  infections  would  appear 
to  vary  with  the  class,  age,  and  complaint  of  the  patients 
examined.  The  number  diagnosed  vary  because  of  slight 
differences  of  opinion  concerning  the  interpretation  of 
dental  roentgenograms.*  If  the  slightest  evidence  of 
bone  absorption  at  the  apex  of  a  devitalized  tooth  is 
considered  evidence  of  sepsis,  then  the  number  of  posi- 
tive findings  is  great,  indeed.  Of  the  total  number  of  de- 

*In  these  statistics  teeth  were  counted  as  abscessed  only  when  the  roentgen 
shadows  had  such  an  appearance  as  would  leave  relatively  little  doubt  in  the  mind  of 
the  average  careful  observer  concerning  the  diagnosis. 

37 


38 


ORAL    SEPSIS 


vitalized  teeth  examined  by  Diveley  and  myself,  the  area 
of  absorption  was  extremely  slight  in  thirty-two  per  cent, 
so  slight  in  fact  that  opinions  would  differ  as  to  whether 


Fig.   37. 


Fig.   39. 


LJ       .* 


Fig.  38. 


Fig.   40. 


Fig.  41. 
Figs.   37-41. — Illustrations   of  large  alveolar  abscesses. 

or  not  they  could  be  looked  upon  as  indicative  of  in- 
fection.    In  forty-nine  per  cent  the  area  was  of  such 


ALVEOLAR   ABSCESSES 


39 


size  and  appearance  as  to  leave  little  doubt  concerning 
the  diagnosis  of  sepsis.  It  is  interesting  to  compare 
these  statistics  with  ..those  reported  by  Black  since  his  ob- 
servations were  made  upon  healthy  individuals  while 
those  above  mentioned  were  made  upon  medical  cases. 
Since  Black  included  in  his  number  of  shadowed  teeth  all 
those  which  showed  evidence  of  bone  absorption  no  mat- 
ter how  small,  his  forty-seven  per  cent  found  in  relatively 
healthy  individuals  would  compare  perhaps  with  our 
eighty-one  per  cent  found  in  individuals  having  systemic 
disorders.  The  actual  percentage  of  devitalized  teeth 
which  become  infected  is,  of  course,  even  greater  than 
these  statistics  would  indicate,  for  the  number  lost  by 
reason  of  infection  are  not  included. 


Fig.  42.  Fig.  43. 

Figs.   42  and  43. — Osteomyelitis   of  the   jaw  derived   from   an   infection   at  the  roots  of 
molar   teeth   which    were   extracted   before    roentgenogram   was   taken. 

The  tendency  of  devitalized  teeth  to  abscess  varies  in 
different  individuals.  A  few  individuals  with  many  de- 
vitalized teeth  have  no  abscesses,  while  many  individuals 
have  an  abscess  at  the  root  of  every  devitalized  tooth. 
An  individual  with  two  or  more  devitalized  is  unusually 
fortunate  if  none  are  abscessed.  Physicians  in  examin- 
ing medical  cases  can  feel  relatively  secure  in  assuming 
that  teeth  which  have  never  been  treated  or  filled,  which 
are  vital,  and  which  appear  outwardly  normal  are  not 
the  seat  of  infection.  This  is  not  invariably  the  case, 
however,  for  abscesses  of  pyorrheal  origin  are  occasion- 
ally found  at  the  roots  of  vital  teeth.  Occasionally  in 


40 


ORAL    SEPSIS 


the  case  of  incisors  irregularity  of  the  teeth  causes  a 
thinning  of  the  anterior  wall  of  the  alveolar  process  to 
such  an  extent  that  a  very  slight  infection  can  reach  the 
apex  of  the  root.  In  this  case  a  large  abscess  may  be 


Fig.  44. 


Fig.  45. 


Fig.  46. 


Fig.  47. 


Fig.  48. 


Fig.  49. 


Figs.   44-49. — Illustration  of  the  less  active  type  of  apical  infection — the  so-called 
granuloma.      Note  exostoses   on  roots   shown  in  Fig.    49. 

found  at  the  root  of  a  normal  appearing  vital  tooth  even 
when  the  gum  shows  surprisingly  little  evidence  of  dis- 
ease. In  a  few  cases  observed  by  the  writer  a  vital 


ALVEOLAR   ABSCESSES 


41 


nerve  evidently  passed  through -a  granuloma.  It  is  in- 
teresting to  mention  the  fact  that  a  vital  nerve  can  be 
exposed  to  the  infected  material  of  an  abscess  for  years 


Fig.  50. 


Fig.   51. 


Fig.  52. 


Fig.  53. 


Fig.  54. 


Fig.  55. 


Figs.  50-55. — Typical  example  of  oral  sepsis  in  a  patient  with  a  great  deal  of 
dental  work.  Hardly  a  tooth  can  be  found  which  is  not  the  site  of  infection.  Note 
the  exostoses  of  the  roots  shown  in  Fig.  55  due  to  chronic  irritation  of  the/  peridental 
membrane. 

and  yet  fail  to  cause  a  single  symptom  which  attracts 
the  attention  of  the  patient.     (See  Fig.  17.) 


42 


ORAL   SEPSIS 


Tooth  pulp  may  be  infected  either  directly  as  a  result 
of  the  decay  or  treatment,  or  indirectly  through  the  me- 
dium of  the  blood  stream.  The  former  source  of  infec- 
tion is  evidently  common.  That  the  latter  source  of  in- 
fection is  a  real  one  is  shown  by  the  fact  that  abscesses 
are  often  found  at  the  roots  of  teeth  whose  pulp  chamber 
lias  not  been  perforated  either  by  treatment  or  decay. 
For  example,  infection  is  occasionally  found  at  the  roots 
of  unerupted  teeth  and  at  the  roots  of  teeth  whose1  pulp 


Fig.  56. 


Fig.   57. 


Fig.   59. 

I'itfs.   56-59. — Example  of  the  occurrence  of   numerous  large  abscesses  in   an  individual 
with  an  excessive  amount  of  dental  work. 

lias  been  killed  by  trauma  or  by  the  proximity  of  large 
fillings.  In  rare  instances  abscesses  are  found  at  the 
roots  of  teeth  which  have  been  neither  treated  nor  in- 
jured. In  one  individual  that  I  observed  three  abscesses 
were  found  at  the  roots  of  the  uninjured,  untreated 
teeth. 

The  importance  of  filling  the  root  canal  to  the  very 


ALVEOLAR    ABSCESSES 


43 


tip  of  the  apex  after  the  devitalization  of  a  tooth  has 
been  repeatedly  emphasized  by  dentists.  It  is  interest- 
ing in  this  connection  to  quote  statistics  recently  re- 


Fig.  60. 


Fig.  61. 


Fig.  62. 


Fig.  63. 


Fig.  64. 


Fig.  65. 


J-'lg.       UT.  •"-   *&•       *• 

Figs.  60-65. — Example  of  an  individual  haying  a  great  deal  of  dental  work,  who 
shows  relatively  little  periapical  sepsis.  This  is  a  rather  unusual  rinding  and  forms 
a  marked  contrast  to  the  cases  illustrated  in -Figs.  31  and  59. 

ported  by  Black  who  found  in  examining  healthy  indi- 
viduals that  of  273  devitalized  teeth  in  which  the  root 
canals  were  relatively  well  filled,  only  23  were  abscessed 


44 


OKAL,   SEPSIS 


(8  per  cent) ;  while  of  580  teeth  in  which  the  root  canal 
was  poorly  filled  379  were  abscessed  (65  per  cent). 

Medical  cases  which  we  have  examined  gave  results 
which  are  somewhat  different  from  the  above.     Of  the 


Fig.  66. 


Pig.  67. 


Fig.  68. 


Fig.  69. 


Fig.  70. 


Fig.  71. 


Figs.    66-71. — Illustration    of    the    commonest    source    of    periapical    infection;    namely, 
devitalized  teeth   with   incompletely  filled   root   canals. 

devitalized  teeth  having  poorly  filled  root  canals  88  per 
cent  were  shadowed.  In  32  per  cent  the  shadows  were 
extremely  small.  In  56  per  cent  the  shadows  were  of 


ALVEOLAR    ABSCESSES 


45 


such  size  and  appearance  as  to  leave  little  doubt  concern- 
ing the  diagnosis  of  sepsis.  Of  the  teeth  having  relatively 
well-filled  root  canals,  52  per  cent  were  shadowed.  In  32 
per  cent  the  shadows  were  extremely  small.  In  20  per 
cent  the  shadows  were  of  such  a  size  and  appearance  that 
they  were  thought  to  indicate  the  presence  of  sepsis  al- 
most positively.  Teeth  whose  root  canals  had  been 
reamed  out  with  broaches  and  carefully  filled  to  the  very 
tip  are  not  included  in  the  above  statistics  for  the  reason 


Fig.  72. 


Fig.  73. 


Fig.  74. 
Figs.   72-74. — Illustration   of  abscesses  due  to  perforation   of  root  by  pins. 

that  too  few  were  found  to  give  reliable  percentages,  and 
also  because  it  was  not  possible  in  the  majority  of  in- 
stances to  determine  whether  such  canals  had  been  well 
filled  immediately  after  devitalization  of  the  nerve,  or 
whether  they  were  abscessed  teeth  which  had  been 
drained  and  filled  a  second  time. 

It  is  interesting  to  note  that  of  all  the  crowned  teeth 
examined  in  which  an  attempt  had  been  made  to  leave 


46 


ORAL   SEPSIS 


the  root  pulp  vital  65  per  cent  were  shadowed.  In  42 
per  cent  the  shadows  were  very  minute.  In  23  per 
cent  one  could  feel  secure  in  making  a  positive  diagnosis 
of  sepsis.  These  findings  are  of  interest  in  showing  the 
necessity  of  care  in  the  crowning  of  vital  teeth.  Among 
the  cases  that  we  have  observed  more  sepsis  was  derived 


Fig.   76. 


Fig.   77. 
Figs.   75-77. — Apical  sepsis  due  to  infection  of  the  pulp  by  decay. 

from  teeth  which  were  left  apparently  vital  when  crowned 
than  from  teeth  which  were  purposely  devitalized  and 
left  with  the  root  canals  only  partly  but  relatively  well 
filled. 

It  is  also  interesting  to  mention  that  93  per  cent  of 
snags  of  teeth  left  by  decay  or  after  extraction  wore 
shadowed,  and  that  in  67  per  cent  the  shadows  wrere  rel- 
atively large  in  size. 

The  time  at  which  root  abscesses  develop  varies.  One 
might  presume  that  in  the  average  case,  it  forms  soon 
after  the  pulp  has  been  destroyed.  This,  however,  ap- 


ALVEOLAR   ABSCESSES 


47 


pears  not  always  to  be  the  case.  Frequently,  an  acute 
abscess  develops  years  after  the  devitalization  of  a 
tooth.  In  a  very  few  instances  in  which  teeth  have  been 
rayed  a  second  time  a  granuloma  has  been  found  on  the 


Fig.  78. 


Fig.  80. 


Fig.   79. 


Fig.  81. 


Fig.  82.  Fig.  83. 

Figs.   78-83. — Examples  of  root  remnants  which   are  the  site  of  infection. 

second  examination  which  apparently  did  not  exist  when 
the  first  roentgenograms  were  made. 

The  mode  of  onset  of  apical  infection  varies.     As  a 
rule,  it  develops  slowly  and  gradually,  causing  no  symp- 


48 


ORAL    SEPSIS 


tonis  by  which  its  presence  might  be  suspected.  In  rare 
instances  it  develops  acutely  soon  after  the  filling  of  the 
root  canal  with  the  production  of  pus  and  a  rapid  de- 
struction of  bony  tissue.  This  type  of  onset  is  usually 


Fig.  84. 


Fig.  85. 


Fig.   86. 


Fig.  87. 


Fig.  89. 

Figs.    84-89. — Examples   of   infection   at   the   apices  of   filled   teeth   whose  pulp   was   not 
intentionally   destroyed. 

associated  with  severe  pain  and  the  constitutional  symp- 
toms of  an  acute  infection.  Such  an  abscess  may  extend 
and  involve  the  roots  of  the  other  teeth.  It  rarely  be- 


ALVEOLAR    ABSCESSES 


49 


comes  so  extensive  as  to  cause  a  definite  osteomyelitis 
of  the  jaw.  The  rarity  of  this  complication  is  probably 
to  be  accounted  for  by  the  fact  that  the  distance  of  the 
abscess  from  the  red  marrow  is  relatively  much  greater 
than  its  distance  from  the  surface  of  the  bone,  in  fact 
there  is  very  little  red  marrow  in  the  jaw  bones  and  this 
is  separated  from  the  alveolar  process  by  a  dense  bony 
structure.  In  other  words,  an  abscess  usually  breaks 
and  discharges  externally  before  it  reaches  the  marrow. 
Abscesses  occasionally  reach  the  subperiosteal  tissue, 
elevate  the  periosteum  to  a  greater  or  less  extent  and 
break  through  and  discharge  externally  for  a  time.  Such 
a  discharge  may  stop  spontaneously  and  may  recur  from 


Fig.  90.  Fig.   91. 

Figs.  90-91. — Examples  of  infection  at  the  root  apices  of  unerupted  teeth. 

time  to  time.  Such  an  abscess  is  not  inclined  to  heal 
permanently  unless  the  tooth  receives  proper  dental 
treatment.  It  may  quiet  down  spontaneously,  however, 
and  develop  into  the  so-called  granuloma.  This  is  more 
frequently  the  case  with  the  smaller  abscesses. 

The  acute  development  of  alveolar  sepsis  as  described 
above  is  the  gross  exception — not  the  rule.  The  usual 
mode  of  onset  is  insidious.  In  a  vast  majority  of  cases 
a  small  mass  of  pus  or  granulation  tissue  forms  at  the 
opening  of  the  root  canal.  It  varies  in  size  from  a  mi- 
nute mass  to  the  size  of  a  pea  or  larger  and  develops, 
as  a  rule,  slowly  and  insidiously  Avithout  causing  pain  or 


50 


ORAL    SEPSIS 


discomfort  and  usually  without  even  causing  tenderness 
of  the  tooth.  Such  granulomata  may  exist  unchanged 
for  years,  may  vary  in  size  from  time  to  time  due  proba- 
bly to  trauma  and  changed  states  of  health.  They  may 
heal  and  recur  spontaneously  and  may  develop  into  an 
acute  abscess  after  years  of  quiescence. 

The  diagnosis  of  alveolar  abscesses  is  made  by  the 
use  of  dental  roentgenograms.  Very  little  can  be  deter- 
mined concerning  their  existence  or  extent  except  by 
this  means.  Unfortunately  there  is  at  present  considera- 
ble divergence  of  opinion  concerning  the  meaning  of  cer- 
tain roentgen  shadows.  There  are  a  few  shadows  which 
occur  at  or  near  the  roots  of  the  teeth  not  caused  by  in- 


Fig.  92. 


Fig.    92. — Example   of  periapical   infection   of   teeth   whose   pulp   was 
severe   trauma.     Two  of  the  root  canals  had  been  filled  just  previous  to 

the  roentgenograms. 


s   destroyed    by 
the  taking  of 


fection  which  simulate  those  caused  by  infection.  Such, 
however,  are  not  common,  and  are  not  the  usual  source 
of  contention.  The  chief  source  of  divergent  opinion 
concerns  whether  or  not  the  shadows  admittedly  due  to 
old  abscesses  or  granulomata  can  be  interpreted  as  proof 
of  active  infection.  Many  dentists  believe  that  certain 
shadows  are  proof  of  past  infection,  but  do  not  believe 
they  can  be  looked  upon  as  evidence  of  active  infection. 
Some  dentists  take  the  extreme  view  that  a  shadow 
means  sepsis  only  when  there  is  pain,  tenderness  of  the 
tooth,  or  other  clinical  manifestation  to  corroborate  the 
diagnosis,  and  often  disregard  roentgen  findings,  which 


ALVEOLAR   ABSCESSES 


51 


as  frequently  happens,  offer  the  only  possible  means  by 
which  root  sepsis  can  be  definitely  proved.  Unanimity 
of  opinion  upon  the  interpretation  of  dental  roentgeno- 
grams  is  naturally  of  fundamental  importance  to  both 


Fig.   93. 


Fig.  94. 


Fig.  95. 


Fig.  96. 


Fig.  97. 

Figs.   93-97. — Examples   of  periapical   infections   of  crowned   teeth   whose   pulp   was   not 

purposely  devitalized. 

physicians  and  dentists,  and  the  lack  of  this  is  a  source 
of  many  contentions.  It  goes  without  saying  that  the 
final  word  concerning  the  interpretation  of  films  should 


ORAL    SEPSIS 


be  said  by  the  dentist,  but  only  by  dentists  who  have 
made  a  careful  study  of  the  subject,  who  have  had  suffi- 
cient experience  in  this  line  to  make  their  opinion  relia- 
ble, and  who  look  upon  sepsis  as  a  serious  condition. 

There  is  considerable  evidence,  although  at  present 
incomplete,  to  show  that  shadows  at  the  apices  of  teeth 
caused  by  the  replacement  of  bone  by  soft  tissue  almost 
invariably  indicate  the  presence  of  infection.  Primarily, 
it  may  be  said  that  a  growth  of  organisms  has  been  ob- 
tained in  culture  by  a  number  of  observers  from  such 
localities,  and  bacteria  have  been  demonstrated  micro- 
scopically in  stained  smears  of  the  material  scraped 
from  the  roots  of  such  teeth.  These  studies,  however. 


Fig.   98.  Fig.   99. 

Figs.    98-99. — Examples  of  periapical   infection   of  untreated   teeth.     Such   teeth   usually 
give  a  history  of  injury,  but  this  is  not  always  the  case. 

are  not  as  yet  complete  enough  to  admit  conclusions 
which  might  be  looked  upon  as  final. 

We  wish  to  suggest  a  second  line  of  evidence  which, 
though  indirect,  seems  rather  convincing.  It  is  a  fact 
well  known  to  pathologists  that  granulating  lesions  in 
bone  almost  invariably  heal  and  become  organized  into 
solid  bone  unless  there  is  a  definite  reason  for  their  not 
doing  so.  The  cause  of  failure  of  such  lesions  to  ossify 
is  usually  infection  or  a  foreign  body  or  a  sequestrum. 
If  such  obstacles  to  healing  are  removed,  organization 
and  ossification  of  the  infected  areas  usually  take  place 
rapidly. 

The  newly  formed  bone  differs  in  its  histologic  struc- 


ALVEOLAE    ABSCESSES 


53 


ture  and  in  gross  architecture  from  normal  bone.  It  dif- 
fers usually  however,  in  being  abnormally  dense,  so  that 
instead  of  casting  roentgen  shadows  showing  areas  of 
diminished  density,  it  more  often  casts  shadows  indicat- 
ing areas  of  increased  density.  Tubercles  of  bone  be- 
come organized  and  ossified  as  soon  as  the  active  tuber- 
culous infection  is  overcome.  Gummata  of  bone  are 
usually  organized  and  transformed  into  solid  dense  bone 
after  antispecific  treatment  .has  been  properly  insti- 
tuted. Likewise  the  granulation  tissue  formed  in  os- 


Fijj.    100. 


Fig.    101. 


Fig.   102: 

Figs.   100-102. — Illustrations  of  teeth  showing  absorption  of  the  tips  of  the  root  apices 
(Figs.  100  and  101)  and  necrosis  of  the  apex  (Fig.  102). 

teomyelitis  is  often  so  completely  ossified  after  the  se- 
questrum is  removed  and  infection  eliminated  by  drain- 
age, etc.,  that  x-ray  pictures  often  show  relatively  little 
difference  between  it  and  the  corresponding  bone  of  tho 
opposite  side.  These  gross  examples  of  the  healing  of 
bone  lesions  lead  one  to  infer  that  areas  relatively  so 
minute  as  granulomata  at  the  roots  of  the  teeth  should 


54 


ORAL   SEPSIS 


ossify  almost  invariably  and  rapidly  unless  there  exists 
a  very  definite  cause  for  their  not  so  doing.  The  cause 
in  this  case  would  appear  usually  to  be  infection.  In 
harmony  with  this  view  is  the  well-recognized  fact  that 
drainage  of  a  root  abscess  followed  by  the  complete  fill- 
ing of  the  root  canal  often  leads  to  disappearance  of  the 
rarefication  shadow  caused  by  it.  The  organization  is 


Fig.    103. 


Fig.   104. 


Fig.    105. 


Fig.    106. 


Figs.   103-106. — Illustrations  of  several  teeth  showing  one  or  more  completely  necrosed 

roots. 

often  so  complete  that  roentgenograms  may  show  rela- 
tively little  evidence  of  its  past  existence.  It  is,  of 
course,  not  always  possible  to  obtain  this  result.  If  the 
periosteum  of  the  root  has  been  extensively  destroyed 
so  that  the  apex  of  the  root  or  the  entire  root  is  necrotic, 
the  condition  remaining  after  drainage  or  after  the  use 
of  antiseptics  is  analogous  in  many  respects  to  osteo- 


ALVEOLAR   ABSCESSES 


55 


Fig.   107. 


Fig.   108. 


Fig.   109. 


Fig.  110. 


Fig.   111. 


Fig.   112. 


L  * 


Fig.  113. 

Figs.  107-113.— Illustrations  of  shadows  indicating  areas  of  increased  density  _in 
the  alveolar  process  as  a  result  of  healing  of  infected  areas.  Shadows  of  such  density 
as  the  above  are  not  commonly  observed. 


56 


ORAL    SEPSIS 


myelitis  in  which  healing  is  prevented  by  a  sequestrum. 
Frequently  it  appears  to  one  that  active  infection  can 
not  exist  for  an  indefinite  period  of  time  in  granulation 
tissue  or  in  the  pus  of  a  chronic  abscess  such  as  an  al- 
veolar abscess  unless  it  be  repeatedly  reinfected  from 
some  source.  The  organisms  in  granulation  tissue  or  in 
chronic  abscesses  are  exposed  to  the  defensive  action  of 
the  blood,  lymphocytes,  leucocytes,  connective-tissue 


Fig.   114. 


Fig.    115. 


Fig.  116. 

Figs.    114-116. — Illustrations    of   radiopaque   areas   which   simulate   the   healed   abscesses 
shown  in  Figs.   107-113. 

cells,  etc.,  and  in  the  course  of  time  are  perhaps  de- 
stroyed by  them.  Organisms  in  the  root  canal  of  non- 
vital  teeth  or  in  the  little  cavities  in  necrotic  portions  of 
the  root,  however,  are  often  safely  removed  from  the 
defensive  mechanism  of  the  body  and  favorably  located 
to  repeatedly  infect  a  granulating  lesion  around  it.  It 
is  probably  for  this  reason  that  the  complete  filling  of  a 


ALVEOLAR   ABSCESSES 


57 


root  canal  or  the  removal  of  the  necrotic  tip  of  a  root 
often  is  followed  by  organization  of  an  abscess. 

The  above  fact  has  been  made  use  of  for  several  years 
by  dentists  in  their  efforts  to  clear  up  root  sepsis  by 


Fig.  117. 

Fig.  117. — Illustration  of  roentgenogram  showing  bone  of  increased  density  due 
apparently  to  increased  stress  transmitted  by  the  tooth  during  mastication.  Areas  of 
increased  density,  such  as  these,  are  not  uncommonly  observed. 


Fig.   118. 


Fig.   119. 


Fig.   12(\ 
Figs.    118-120. — Examples    of    root  remnants   which   have   apparently   become   encysted. 

conservative  means.    The  question  as  to  whether  or  not 
this  method  of  treatment  is  thorough  and  reliable,  how- 


58  ORAL    SEPSIS 

ever,  is  still  an  open  one.  Several  observers  have  been 
able  to  obtain  cultures  of  streptococci  from  the  roots 
of  teetli  treated  in  this  way  even  after  nearly  perfect 
organization  of  the  granuloma  could  be  demonstrated 
roentgenologically.  On  the  basis  of  this  work  such 
teeth  would  appear  theoretically,  therefore,  to  remain 
possible  sources  of  systemic  infection.  Numerous  pa- 
tients under  our  observation  with  systemic  disturb- 
ances, however,  have  been  very  definitely  improved  in 
general  health  after  conservative  methods  of  treatment. 
The  question  as  to  the  best  method  of  treatment  might 
yet  be  considered  an  open  one  and  for  the  present  at 
least  the  choice  of  method  in  each  individual  case  might 
be  based  in  part  upon  the  apparent  possibility  of  eradi- 
cating sepsis  by  conservative  means  and  in  part  upon 
the  gravity  of  the  systemic  ill  for  which  the  teeth  might 
appear  to  have  been  contributing  causes.  The  following 
illustrations  (Figs.  121  to  151)  show  the  value  of  roent- 
genograms  in  determining  the  end  result  of  conservative 
methods  of  treatment. 


ALVEOLAR   ABSCESSES  59 


FIGS.  121-151. 

Examples  showing  the  effect  of  palliative 
measures  in  the  treatment  of  alveolar  ab- 
scesses. Note  the  variability  in  the  final  result. 
In  many  instances  the  abscesses  were  organ- 
ized to  a  greater  or  lesser  degree  after  drain- 
age followed  by  the  use  of  antiseptics  and 
complete  filling  of  the  root  canal;  in  others  no 
marked  evidence  of  organization  could  be  ob- 
served in  roentgenograms.  These  prints  are 
not  perfect  reproductions  of  the  roentgeno- 
grams, and  make  the  palliative  measures  ap- 
pear more  favorable  than  is  actually  portrayed 
in  the  films.  The  systemic  condition  of  the 
patient  in  several  instances  improved  markedly 
after  the  palliative  measures  illustrated  here. 

We  do  not  wish  to  comment  upon  the  ade- 
quacy of  the  results  shown  herd  since  this  is  as 
yet  an  open  question  and  may  not  prove  so 
favorable  as  the  roentgenograms  might  lead  one 
to  believe. 

The  root  canal  work  shown  in  these  illustra- 
tions was  done  by  Drs.  J.  E.  Huff,  Jerome 
Stuart,  H.  V.  Brockett,  A.  C.  Erdman,  M.  C. 
Carpenter,  R.  N.  Seibel,  F.  W.  Franklin,  H.  S. 
Lowry,  E.  M.  Hall,  D.  E.  Taylor,  and  C.  J. 
Davis. 


60 


Fig.   121. 


Fig.   122. 


Fig.   123. 


Fig.   124. 


Fig.     121. — Roentgcnogram    taken    immediately    after    drainage    and    filling    of    the 
oot  canal. 

Fig.    122. — Roentgenogram   of   the   same   tooth    approximately    one   year   later. 

Fig.   123. — Roentgenogram  taken  just  before  drainage  artd   filling  of  the  root  canal. 

Fig.    124. — Roentgcnogram   of  the  same  tooth  two  months   later. 


ALVEOLAR   ABSCESSES 


61 


Fig.  125 


Fig.  126. 


f      I 


Fig.   127. 


Fig.   128. 


Fig.    12S. — Roentgenogram   showing  small   area   of  apical   sepsis. 

Fig.  126.- — Roentgenogram  of  same  tooth  taken  approximately  six  months  after 
its  treatment. 

Fig.   127. — Roentgenogram  showing  small  area  of  apical  sepsis. 

Fig.  128.— Roentgenogram  showing  same  tooth  approximately  three  months  after 
its  treatment. 


62 


ORAL   SEPSIS 


Fig.   129. 


Fig.   130. 


Fig.   131. 


Fig.    129. — Roentgenogram    showing   apical   infection. 

IMK.    130. — Roentgenogram   taken   shortly  after   the   filling   of   the   root   canal. 

Fig.    131. — Roentgenogram  1aken  approximately  eight   months  later. 

This    abscess    was    organized    in    large    degree    in    spite    of    the    fact    that    the    root 
canal    was    not   perfectly   filled    and    the    tip    of    the   apex    was   very   evidently    necrotic. 


ALVEOLAR   ABSCESSES 


63 


Fig.  132. 


Fig.   133. 


Fig.   134. 

Fig.  132. — Roentgenogram  showing  an  abscess  at  the  root  of  a  crowned  left 
upper  incisor.  The  abscess  had  burrowed  to  the  right  and  discharged  near  the  root 
apex  of  the  right  upper  incisor.  Bismuth  had  been  injected  into  the  sinus  some  months 
previous  and  shows  as  a  dense  opacity  in  the  roentgenogram. 

Fig.  133. — Roentgenogram  taken  three  months  after  irrigation  through  the  root 
canal  of  the  left  incisor  followed  by  filling  of  the  root  canal. 

Fig.   134. — Roentgenogram  taken  six  months  after  treatment. 

Organization  of  the  abscesses  in  this  case  was  very  rapid.  A  change  considerable 
in  degree  was  noticed  after  a  few  weeks. 


64 


ORAL   SEPSIS 


Fig.   135. 


Fig.   136. 


Fig.   137. 


Fig.  138. 


3  later. 

nately    one    year    after    completion    of 


ALVEOLAR    ABSCESSES 


65 


Fig.  141. 


Fig.   142. 


Fig.   144. 


Fig.   143. 


Fig.  146. 


Fig.   145. 

Fig.  140. — Roentgenogram  showing  large- 
alveolar  abscess. 

Fig.  141. — Roentgenogram  taken  ten 
we»ks  after  treatment. 

Fig.  142. — Roentgenogram  taken  four 
months  after  complete  filling  of  root 
canal. 

Fig.  143. — Roentgenogram  showing  an 
abscess  at  the  roots  of  two  lower  incisor 
teeth. 

Fig.  144. — Roentgenogram  taken  during 
treatment  of  abscess. 

Fig.  145. — Roentgenogram  taken  immedi- 
ately after  completion  of  treatment. 

Fig.  146. — Roentgenogram  taken  approx- 
imately one  year  after  completion  of  treat- 
ment. Failure  in  result  due  apparently  to 
fact  that  tooth  was  necrotic. 


OTtAL   SEPSIS 


Fig.  147. 


Fig.   149. 


Fig.   ISO. 


Fig.   151. 


Fig.   152. 


Fig.  147. — Koentgcnogram  showing  large  discharging  alveolar  abscess  at  the  apex 
ol  a  lower  incisor  tooth. 

Fig.  148. — Roentgenogram  taken  approximately  four  months  after  completion  of 
treatment.  No  evidence  of  healing  is  discernible  in  spite  of  the  fact  that  the  abscess 
was  irrigated  and  drained  and  the  root  canal  filled  to  the  apex. 

Fig.  149. — Roentgenogram  showing  an  abscess  at  the  root  of  an  upper  bicuspid 
tooth. 

Fig.  150. — Roentgenogram  of  the  same  tooth  taken  approximately  six  months  after 
treatment.  No  organization.  Root  canal  not  properly  filled. 

Fig.    151. — Roentgenogram  showing  an  abscessed  lower  molar  tooth. 

Fig.    152. — Roentgenogram    taken   approximately   three   mon:hs   after    completion    of 

treatment. 


ALVEOLAR    ABSCESSES  67 


FIGS.  153-161. 

Examples  of  careful  root  canal  work.  More 
is  accomplished  by  careful  laborious  work  such 
as  the  following  if  it  is  directed  towards  pre- 
vention of  sepsis  rather  than  towards  its  cure. 
It  is  stated  by  dentists  that  periapical  sepsis 
can  usually  be  prevented  if  root  canals  are 
filled  in  this  way  immediately  after  devitaliza- 
tion  of  the  pulp. 

The  best  interest  of  the  patient  demands  that 
root  canals  be  filled  in  this  way  and  that  the 
thoroughness  of  the  result  be  determined  by  the 
use  of  roentgenograms. 

Note  multiple  apical  foramina  shown  in  Fig. 
156  and  lateral  accessory  foramina  shown  in 
Figs.  157  and  158. 

Koentgenograms  taken  by  Dr.  J.  A.  Sawhill. 


68 


ORAL    SEPSIS 


Fig.   153. 


Fig.   154. 


Fig.   155. 


ALVEOLAR    ABSCESSES 


69 


Fig.    156. 


Fig.  157. 


Fig.   158. 


70 


ORAL    SEPSIS 


Fig.   1S9. 


Fig.   160. 


Fig.   161. 


CHAPTER  IV 
METASTATIC  INFECTION 

The  spread  of  infection  from  a  chronic  focus  occurs 
in  three  ways,  by  direct  extension  to  adjacent  tissues,  by 
transportation  along  mucous  or  serous  surfaces,  and  by 
metastatic  infection  through  the  medium  of  the  blood 
stream  and  lymph  with  the  final  involvement  of  distant 
organs.  The  last  mentioned  type  of  infection  is  by  far 
the  most  important. 

The  animal  organism  gains  an  immunity  against 
chronic  infections  and  is  often  able  under  the  usual  con- 
ditions of  life  to  keep  them  localized.  Invasion  of  the 
blood  and  spread  from  chronic  foci  occur  usually  dur- 
ing periods  when  resistance  is  lowered  by  the  effect  of 
such  conditions  as  fatigue,  exposure,  digestive  disturb- 
ance, lack  of  proper  nourishment,  overindulgence  in  al- 
cohol, pregnancy  and  lactation,  diabetes,  anemia,  debili- 
tating diseases,  acute  and  chronic  infections,  etc.  The 
important  influences  of  these  factors  upon  the  defen- 
sive mechanism  has  been  repeatedly  observed  both 
clinically  and  experimentally.  One  might  quote  in  this 
connection  the  discoverey  of  Pasteur  that  fowls  which  are 
naturally  immune  to  anthrax  become  susceptible  to  the 
disease  if  the  body  temperature  is  reduced  by  a  cold 
bath,  also  the  discovery  of  Charrin  and  Roger  that  white 
rats  which  enjoy  a  similar  immunity  against  anthrax  be- 
come quite  susceptible  if  they  are  exhausted  by  physical 
exertion.  Organisms  harbored  in  such  chronic  foci  of  in- 
fection as  alveolar  abscesses  are  held  local  a  large  part 
of  the  time.  They  repeatedly  find  the  defenses  of  the 
body  below  par,  however,  and  find  abundant  opportunity 

71 


72  ORAL   SEPSIS 

to  multiply  rapidly,  invade  the  blood  and  gain  lodgement 
in  distant  structures. 

A  variety  of  organisms  can  be  obtained  in  culture 
from  periodontal  infections.  Streptococcus  viridans  is 
found  more  constantly  in  the  deeper  pyorrhea  pockets 
and  in  alveolar  abscesses  than  other  organisms,  and  usu- 
ally predominates  in  number.  Of  the  meta static  infec- 
tions attributable  to  focal  infection,  those  caused  by  the 
streptococcus  group  appear  to  be  the  most  important  and 
have  been  the  subject  of  most  extended  study. 

A  new  and  interesting  conception  of  infection  and  of 
diseases  caused  by  streptococci  has  been  suggested  by 
Rosenow,  Billings,  and  their  coworkers  as  a  result  of 
extensive  laboratory  and  clinical  investigations  carried 
on  during  the  past  few  years.  The  conclusions  which 
these  observers  have  drawn  have  not  been  accepted  in 
their  entirety,  and  have  recently  been  the  subject  of  much 
discussion  and  controversy.  While  some  of  the  views 
Avhich  they  express  may  prove  fallacious,  others  which 
are  of  fundamental  importance  will  undoubtedly  stand. 
The  more  important  suggestions  which  they  have  made 
are:  First,  that  the  number  of  diseases  caused  by  strep- 
tococci is  greater  than  was  formerly  supposed;  second, 
that  streptococci  may  acquire  affinities  for  certain  tis- 
sues, which  in  many  instances  is  remarkably  specific: 
third,  that  streptococci  may  change  in  their  selective 
affinities,  morphology  and  cultural  characteristics  and 
biologic  reactions  after  cultivation  in  artificial  media  or 
after  growth  in  animal  tissues. 

The  fact  that  streptococci  can  acquire  an  affinity  for  a 
certain  specific  tissue  was  suggested  earlier  by  Forssner 
who  working  with  a  strain  of  streptococcus  obtained 
from  an  abscess  which  had  no  particular  affinity  for  kid- 
ney tissue  stated  that  he  was  able  to  develop  such  an 
affinity  in  the  organism  by  taking  cultures  from  the  kid- 
nev  lesions  of  animals  which  he  had  inoculated  with  the 


METASTATIC    INFECTION  73 

nonspecific  culture.  This  affinity  was  lost  after  several 
transplants  in  bouillon. 

Billings  and  Eosenow  conclude  from  their  observa- 
tions that  members  of  the  streptococcus  pneumococcus 
group  may  develop  affinities  for  certain  tissues,  not  only 
while  growing  in  those  particular  tissues,  but  also  while 
growing  in  primary  foci  of  infection.  They  state  that 
the  organisms  obtained  from  the  infected  tissue  of  pa- 
tients with  such  diseases  as  appendicitis,  cholecystitis, 
gastric  and  duodenal  ulcer,  glomerular  nephritis,  rheu- 
matism, endocarditis,  etc.,  show  striking  similarities  in 
their  elective  affinities  to  the  organisms  obtained  from 
the  related  foci  of  infection.  They  found  the  elective 
affinity  less  marked,  however,  in  the  strains  isolated  from 
the  primary  foci. 

The  interesting  deduction  is  made  by  Eosenow  that 
since  bacteria  which  have  grown  in  given  tissues  acquire 
an  affinity  for  that  tissue,  the  likelihood  of  such  organ- 
isms to  involve  structures  of  a  different  nature  is 
relatively  slight  and  that  a  focus  in  a  specialized  tis- 
sue, therefore,  would  seem  less  important  as  a  distribu- 
tor of  bacteria  than  the  primary  focus.  He  believes  that 
bacteria  growing  in  primary  foci  not  localized  in  special- 
ized tissue  can  change  in  their  affinities  and  invade  one 
type  of  tissue  after  another.  For  example,  bacteria 
which  have  localized  in  joints  and  acquired  a  special  elec- 
tive affinity  for  joint  structures  are  less  likely  to  spread 
to  other  organs  such  as  the  appendix,  kidney,  gastric 
mucosa,  etc.,  than  organisms  localized  in  nonspecialized 
tissues,  such  as  tonsillar  crypts,  alveolar  abscesses,  etc., 
where  they  are  constantly  subjected  to  varying  condi- 
tions of  oxygen  tension,  and  where  they  may  be  changed 
thereby  in  their  nature  and  affinities  just  as  they  may  be 
changed  by  various  artificial  conditions  when  grown  in 
culture  media. 

The  above  conclusions  concerning  selective  affinity  of 


74  ORAL    SEPSIS 

organisms  and  transmutation  of  strains  arc  not  alto- 
gether radically  opposed  to  views  held  formerly.  It  has 
long  been  known  that  the  tendency  of  organisms  to  lo- 
calize depends  to  a  certain  extent  on  virulence,  and  that 
the  virulence  of  an  organism  is  changed  by  environment. 
Rosenow's  elaboration  has  been  so  extensive,  however,, 
as  to  almost  revolutionize  former  views  concerning  in- 
fection. It  is  quite  proper  that  conclusions  so  interest- 
ing and  of  such  fundamental  importance  be  carefully 
analyzed  by  other  observers,  and  that  their  full  accept- 
ance await  repeated  verification. 

While  Rosenow's  interesting  experiments  suggest  in 
detail  the  mechanism  by  which  certain  tissues  are  in- 
fected, their  acceptance  is  not  essential  to  the  popular 
view  that  many  acute  and  chronic  diseases  are  attribut- 
able to  infection  distributed  by  small  foci  of  infection 
and  that  streptococci  distributed  by  them  may  cause  sys- 
temic diseases  whose  gravity  seems  out  of  all  proportion 
to  the  size  and  activity  of  the  original  apparently  trivial 
focus. 

There  is  also  little  question  concerning  the  fact  that 
streptococci  which  have  been  isolated  from  tissues  in  a 
great  variety  of  diseases  upon  inoculation  into  rabbits 
produce  in  a  majority  of  cases  pathologic  changes  simi- 
lar to  those  in  the  tissues  from  which  the  organisms  were 
originally  obtained;  nor  concerning  the  fact  that  the 
predominating  organism  isolated  from  a  focus  of  infec- 
tion may  produce  upon  inoculation  into  animals  the 
same  pathologic  changes  as  the  organism  obtained  from 
the  diseased  tissue  which  derived  its  infection  from  the 
focus. 

The  following  diseases,  often  streptococcic  in  origin, 
may  originate  as  a  metastatic  infection  from  chronic  foci 
of  infection  such  as  pyorrhea  alveolaris  and  alveolar  ab- 
scesses :  Rheumatic  fever,  acute  and  chronic  infectious  ar- 
thritis, myositis,  bursitis,  neuritis,  iritis,  and  other  inflam- 


METASTATIC    INFECTION  75 

matory  diseases  of  the  eye  including  possibly  neuroretini- 
tis,  vegetative  endocarditis,  ulcerative  endocarditis,  myo- 
carditis, pericarditis,  phlebitis,  peritonitis,  chorea,  spinal 
myelitis,  meningitis,  acute  and  chronic  nephritis,  acute 
and  chronic  appendicitis,  cholecystitis,  gastric  and  duo- 
denal ulcer,  pancreatitis,  thyroiditis,  erythema  nodosum, 
herpes  zoster,  osteomyelitis,  periostitis,  pneumonia,  pleu- 
risy, empyema,  septicemia,  erysipelas,  cellulitis,  lymph- 
adenitis, etc. 

It  is  generally  recognized  and  has  been  emphasized 
by  Rosenow  that  streptococci  have  general  virulence  as 
well  as  selective  affinities  for  certain  tissues.  Strepto- 
cocci obtained  from  acute  arthritis  upon  injection  in  rab- 
bits infect  not  only  the  joints,  but  also,  in  a  minority  of 
cases,  other  organs,  such  as  gall  bladder,  gastric  mucosa, 
endocardium,  myocardium,  etc.  The  general  virulence  of 
an  organism  is  of  considerable  importance  in  the  patho- 
genesis  of  disease  and  often  causes  spread  of  an  infec- 
tion to  tissues  for  which  it  has  no  selective  affinity.  This 
is  especially  the  case  during  periods  when  resistance  is 
low. 

Resistance  may  be  lowered  locally  as  well  as  generally. 
It  may  be  lowered  locally  by  many  types  of  trauma, 
strain,  intoxication,  lack  of  local  nourishment,  local  in- 
terference with  blood  supply,  etc.  To  illustrate  this 
factor  it  may  be  mentioned  that  individuals  with  rheu- 
matism frequently  notice  the  involvement  of  a  new  joint 
following  some  slight  injury  to  the  joint.  In  fact,  in 
chronic  arthritis  the  joints  most  commonly  involved  are 
those  subjected  to  frequent  slight  trauma.  The  joints 
of  the  fingers  are  commonly  involved  in  individuals  who 
use  their  hands  a  great  deal,  the  hip  joints  in  delivery 
men  who  frequently  jump  from  their  wagons,  the  ankle 
joints  in  individuals  who  have  flatfoot  with  the  unusual 
strain  on  the  ligaments  caused  by  this  condition,  the 
knees  in  individuals  whose  knee  joints  are  strained  by 


76 


ORAL    SEPSIS 


reason  of  gonu  valgus,  the  joints  of  the  spine  in  indi- 
viduals with  postural  defects,  etc.  These  examples  illus- 
trate the  influence  of  strain  and  trauma  in  determining 
the  localization  of  organisms  which  already  have  affini- 
ties for  given  types  of  ^tissue  (in  the  examples  mentioned 
affinity  for  joint  structure).  Local  injury  may  also  lead 
to  the  infection  of  tissues  by  organisms  which  have  no 
especial  predilection  for  them.  For  example,  local  injury 
to  a  bone  may  cause  osteomyelitis  by  rendering  the  tis- 


Fig.   162. 


Fig.   163. 


Fig.   164. 

Fig.  162. — Case  of  chronic  migratory  polyarthritis  of  several  months'  duration 
which  was  completely  relieved  by  the  extraction  of  the  tooth  shown  in  the  above 
illustration. 

Fig.  163. — Case  of  multiple  neuritis  of  some  six  months'  duration  which  was 
completely  relieved  by  the  extraction  of  the  tooth  shown  in  above  illustration. 

Fig.  164. — Case  of  recurrent  pain  in  gall  bladder  region  associated  with  occasional 
slight  jaundice  which  was  apparently  relieved  by  the  extraction  of  the  tooth  shown 
in  above  illustration.  Cholecystotomy  had  been  advised  and  refused  by  the  patient 
before  the  tooth  was  extracted. 

sues  suitable  for  the  growth  of  organisms  which  origi- 
nally had  no  apparent  specific  affinity  for  bone  marrow. 
Opie  was  able  to  combine  chloroform  poisoning,  which 
causes  a  high  grade  of  liver  necrosis,  with  the  inocula- 


METASTATIC    INFECTION  77 

tion  of  living  organisms  of  varying  virulence  and  pro- 
duce pathologic  changes  in  the  liver  analogous  to  acute 
yellow  atrophy  and  cirrhosis  of  the  liver.  The  changes 
observed  were  apparently  dependent  in  part  upon  the 
degree  of  injury  to  the  liver  cells  produced  by  the  chloro- 
form, and  in  part  upon  the  general  virulence  of  the  or- 
ganisms used.  He  was  not  able  to  produce  changes  typi- 
cal of  either  of  the  above  diseases  by  chloroform  poison- 
ing alone  or  by  infection  alone.  His  deduction  that  the 
above  diseases,  in  humans  might  be  due  to  a  combined  ef- 
fect of  toxemia  and  infection  appears  to  be  wrell  founded. 
The  strain  of  organisms  used,  of  course,  had  no  specific 
affinity  for  liver  tissue.  Opie's  experiments  explain  pos- 
sibly the  fact  that  alcohol,  which  figures  so  frequently  in 
the  etiology  of  hepatic  cirrhosis,  may  be  indulged  in  ex- 
cessively over  a  period  of  years  by  many  individuals 
without  the  appearance  of  cirrhotic  change.  Possibly  the 
liver  of  a  normal  individual  can  tolerate  an  amount  of 
abuse  by  alcohol  and  other  poisons  which  might  lead 
to  chronic  inflammatory  changes  ending  in  liver  cirrhosis 
in  individuals  suffering  from  chronic  infection  such  as 
oral  sepsis,  tuberculosis,  syphilis,  etc. 

The  various  organs  and  tissues  of  the  body  are,  of 
course,  repeatedly  subjected  to  conditions  which  increase 
their  susceptibility  to  infection,  such  as  local  strain,  ex- 
haustion, trauma,  local  interference  with  the  blood  sup- 
ply, obstruction  of  the  excretory  ducts  by  stones,  and 
by  the  effect  of  toxins  and  poisons  of  many  kinds.  Such 
conditions  might  be  tolerated  by  normal  individuals  but 
might  lead  to  local  infection  and  serious  disease  in  indi- 
viduals having  chronic  infections.  It  is  perhaps  possible 
in  this  way  to  account  for  the  existence  of  widespread 
systemic  disease  in  some  individuals  having  focal  infec- 
tions and  its  total  absence  in  others  who  have  similar 
foci.  Chronic  infections  are  probably  of  more  serious  mo- 
ment in  individuals  whose  systems  are  subject  to  injury 


78  ORAL    SEPSIS 

by  other  agents.  Conversely,  abuses  of  any  sort  would 
appear  of  more  serious  moment  in  individuals  having 
chronic  infections  than  in  individuals  who  are  free  from 
them. 

The  importance  of  oral  sepsis  as  a  source  of  metastatic 
infection  is  not  small.  It  is  the  most  common  of  the 
chronic  infections,  therefore  one  of  the  more  important. 
It  is  a  less  apparent  source  of  disease  than  the  tonsils. 
The  difference  is,  however,  probably  more  apparent  than 
real. 

Systemic  infection  attributable  to  oral  sepsis  is  usually 
chronic  and  insidious  in  onset.  The  effects  are  so  in- 
sidious that  the  resulting  pathologic  changes  are  often 
extreme  in  grade  before  they  are  noticed  clinically.  For 
this  reason  the  treatment  of  oral  sepsis  does  not  always 
give  the  relief  that  might  be  hoped  for. 

The  inflammatory  process  in  a  given  lesion,  arthritis, 
for  example,  often  continues  long  after  the  primary  focus 
of  infection  is  removed.  This  may  be  due  in  part  to  the 
fact  that  the  organisms  have  produced  local  pathologic 
changes  in  the  tissues  which  are  favorable  to  their  growth 
and  in  part  to  the  fact  suggested  by  Welch  that  organisms 
in  their  struggle  for  existence  in  the  tissues  of  an  indi- 
vidual may  acquire  the  faculty  of  protecting  themselves 
against  his  defensive  mechanism.  Either  factor  might 
render  difficult  or  impossible  their  thorough  and  com- 
plete eradication  from  the  tissues. 


CHAPTER  V 

NONRELATED  INFECTION  AS  INFLUENCED  BY 
ORAL  SEPSIS 

It  is  generally  recognized  that  when  an  individual  has 
two  or  more  diseases,  one  may  influence  the  other  oc- 
casionally to  the  apparent  advantage  of  the  patient,  but 
more  frequently  to  his  disadvantage.  In  other  words, 
increased  susceptibility  to  one  organism  may  be  caused 
by  infection  with  another.  This  can  be  well  illustrated 
by  familiar  clinical  examples.  Latent  tuberculosis  may 
become  active  after  an  attack  of  tonsillitis,  bronchitis, 
or  la  grippe.  It  was  mentioned  in  a  previous  chapter 
that  a  patient  who  had  latent  specific  disease  was  cov- 
ered with  a  copper-colored  rash  and  gave  a  positive  Was- 
sermann  reaction  at  the  end  of  the  first  week  of  con- 
valescence from  typhoid  fever.  Urethritis  is  often  un- 
favorably influenced  by  the  appearance  of  a  new  disease, 
and  apparently  cured  cases  may  recur  after  an  attack 
of  tonsillitis  or  la  grippe.  In  a  patient  observed  by  us 
an  attack  of  bronchopneumonia  followed  several  days  af- 
ter the  development  of  an  acute  alveolar  abscess  which 
required  lancing.  Several  weeks  afterward  the  patient 
had  a  recurrence  of  active  tuberculosis  which  had  been 
latent  for  many  years. 

It  is  frequently  observed  that  infections  of  a  milder 
nature,  such  as  chronic  oral  sepsis,  chronic  tonsillitis, 
etc.,  may  have  an  untoward  influence  upon  the  course  of 
other  unrelated  infectious  diseases  with  which  an  indi- 
vidual may  be  afflicted.  This  influence  is  often  quite 
marked.  The  ill  effect  of  chronic  mild  infections  of  the 
nose  and  throat  upon  tuberculous  individuals  is  recog- 
nized, and  proper  local  measures  are  looked  upon  as  an 

79 


80 


ORAL    SEPSIS 


important  part  in  the  regime  for  the  treatment  of  tuber- 
culosis. Oral  sepsis  also  may  exert  an  unfavorable  in- 
fluence upon  the  course  of  tuberculosis  and  marked  im- 
provement may  follow  the  removal  of  abscessed  teeth. 
According  to  the  observations  of  my  friend,  Dr.  Richard 
L.  Sutton,  chronic  infections  of  the  skin,  such  as  acne 
and  furunculosis,  are  often  favorably  influenced  by  the 
removal  of  focal  infections  in  which  streptococci  may 
be  the  dominant  organisms.  In  a  patient  with  staphylo- 
coccus  aureus  septicemia  a  fall  of  four  degrees  in  tem- 
perature occurred  several  hours  after  the  removal  of  a 
chronically  abscessed  tooth  which  showed  a  pure  growth 
of  streptococcus  viridans  on  culture.  The  temperature 


Fig.   165. 

Fig.  165. — Case  of  staphylococcus  septicemia  of  about  two  months'  duration.  Tem- 
perature, which  has  been  constantly  reaching  102°  or  over  each  day,  dropped  to  normal 
a  few  hours  after  the  extraction  of  the  tooth  shown  in  the  above  illustration  and 
remained  normal  for  ten  days.  The  case  ended  in  complete  recovery.  The  root 
apices  showed  streptococcus  viridans  in  pure  growth  when  cultured. 

remained  normal  for  ten  days  following  this,  and  the 
case  eventually  recovered.  The  temperature  had  reached 
102°  each  day  for  the  previous  two  months.  (Fig.  165.) 

The  ill  effect  of  focal  infections  upon  individuals  with 
syphilis  of  the  nervous  system  is  very  great  indeed.  This 
will  be  dealt  with  in  some  detail  on  account  of  its  great 
practical  importance.  The  Wassermann  test  made  as  a 
routine  in  one  thousand  medical  cases  observed  in  office 
practice  was  positive  in  11  per  cent.  Involvement  of  the 
nervous  system  was  found  clinically  and  verified  by  lum- 
bar puncture  in  over  50  per  cent  of  these ;  that  is,  in  ap- 


NONRELATED    INFECTION   AND    ORAL   SEPSIS  81 

proximately  6  per  cent  of  the  total  number  of  medical 
cases  examined.  The  overwhelming  majority  of  these 
had  several  alveolar  abscesses.  The  occurrence  of  syph- 
ilis of  the  central  nervous  system  and  alveolar  abscesses 
in  the  same  individual  is,  therefore,  a  very  common  oc- 
currence. The  fact  that  nonrelated  infections  may  rap- 
idly hasten  the  course  and  augment  the  symptoms  of 
tabes  dorsalis  is  well  illustrated  by  the  following  case 
history  which  may  be  reported  briefly  as  follows : 

Patient,  male,  age  thirty-five,  had  been  treated  for  two 
years  for  tabes  dorsalis.  Before  treatment  was  started 
he  had  noticed  slight  ataxia  and  bladder  disturbance  and 
was  subject  to  mild  attacks  of  darting  pain  in  the  legs. 
He  improved  very  satisfactorily  under  antispecific  treat- 
ment, and  after  he  had  been  free  from  pain  and  bladder 
disturbance  for  more  than  a  year,  he  had  an  attack  of 
acute  tonsillitis.  With  the  onset  of  this  there  followed 
a  recurrence  of  the  most  severe  lightning  pains  which 
the  patient  had  ever  experienced.  Morphine  and  salicyl- 
ates  to  the  limit  were  required  to  keep  the  patient  out 
of  agony.  There  was  nothing  to  account  for  the  sudden 
recurrence  of  acute  symptoms  unless  it  were  tonsillitis. 
A  tonsillar  abscess  developed,  and  when  this  was  lanced, 
lightning  pains  ceased  immediately  and  almost  com- 
pletely. A  few  slight  pains  \vere  noticed  until  the  ton- 
sils were  removed  some  three  weeks  later.  During  two 
years,  since  that  time,  the  patient  has  been  practically 
free  from  any  active  symptoms  of  tabes  and  has  required 
very  little  treatment  of  any  kind  to  prevent  recurrence 
of  his  previous  symptoms. 

The  above  case  was  very  striking  indeed  and  convinc- 
ing of  the  fact  that  unrelated  infections  may  have  an 
untoward  influence  on  the  course  of  tabes  dorsalis  which 
is  by  no  means  small.  All  the  symptoms  in  early  cases, 
including  lightning  pains,  numbness,  paresthesia,  ataxia, 
visceral  disturbances,  etc.,  appear  to  be  made  worse  by 
them. 


82  ORAL    SEPSIS 

For  two  years  all  cases  of  syphilis  that  we  have  treated 
have  been  urged  to  have  every  source  of  infection  radi- 
cally removed  if  possible.  The  patients  with  tabes  have 
been  benefited  by  this  almost  without  exception.  Some 
who  were  running  rather  unfavorable  courses,  in  spite 
of  antispecific  treatment,  began  to  improve  immediately. 
The  following  is  mentioned  as  a  typical  example : 

Patient,  age  fifty  years ;  case  had  been  diagnosed  gen- 
eral paresis  and  had  been  given  thorough  antispecific 
treatment  for  two  years.  When  he  came  under  our  ob- 
servation, he  was  unable  to  attend  to  business,  and  had 
to  spend  most  of  his  afternoons  in  bed.  All  known 
methods  of  treatment  had  been  pushed  to  the  limit  and 
it  appeared  that  very  little  improvement  could  be  ex- 
pected from  further  antispecific  therapy.  The  patient 
had  large  tonsils  and  several  abscessed  teeth.  These 
were  removed.  The  patient  improved  steadily  and  to  an 
unbelievable  degree  from  the  date  of  the  above  opera- 
tions. Within  less  than  a  month  he  was  able  to  engage 
in  active  business  again.  He  has  continued  mild  anti- 
specific  treatment,  and  has  remained  in  active  business 
since  that  time. 

If  thorough  and  radical  removal  of  all  sources  of 
chronic  infection  precedes  the  antispecific  treatment  of 
tabes  and  paresis  the  improvement  is  often  so  striking 
and  gratifying  to  the  patient  that  it  is  occasionally  diffi- 
cult to  persuade  him  to  undergo  the  hardships  of  inten- 
sive treatment  with  salvarsan  and  mercury.  The  follow- 
ing case  is  mentioned  as  a  typical  result  of  removal  of 
focal  infection  in  a  previously  untreated  patient  with 
tabes  dorsalis  whose  disease  had  been  running  a  rapidly 
progressive  course. 

Patient,  male,  age  forty-five,  was  brought  in  with  a 
diagnosis  of  tabes  dorsalis.  Physical  and  laboratory  er- 
aminations  left  no  doubt  concerning  this.  The  onset  had 
been  stormy  and  for  three  weeks  the  patient  had  been 


KONEELATED    INFECTION    AXD    DEAL    SEPSIS  83 

fairly  convulsed  with  lightning  pains  and  had  hardly 
been  able  to  control  himself.  He  was  so  nervous  and  ir- 
ritable at  the  time  of  the  examination  that  it  was  almost 
impossible  to  get  him  to  remain  quiet  long  enough  to 
obtain  a  specimen  of  blood  for  examination.  Lumbar 
puncture  could  not  have  been  done  without  general  anes- 
thesia. Dental  films  showed  an  advanced  degree  of 
sepsis.  The  abscessed  teeth  were  all  extracted.  Within 
a  few  days  the  patient  was  so  improved  that  he  went 
back  to  work.  He  felt  and  acted  like  a  well  man  even 
though  antispecific  treatment  had  not  yet  been  adminis- 
tered. 

Many  cases  similar  to  the  above  could  be  cited.  These 
are  not  picked  cases,  but  represent  only  an  average  ex- 
perience. Nearly  all  the  cases  of  tabes  dorsalis  that  we 
have  treated  have  been  early  cases,  and  those  in  whom 
it  has  been  possible  to  remove  every  other  source  of  infec- 
tion have  responded  splendidly  to  antispecific  treatment, 
and  have  apparently  required  less  treatment  than  was 
formerly  used  to  stop  the  progress  of  the  disease.  Kap- 
idly  progressive  cases  of  tabes  and  paresis  usually  show 
many  sources  of  infection  and  usually  run  a  milder 
course  which  can  be  controlled  by  antispecific  treatment 
if  all  such  infections  are  radically  removed.  Severe  light- 
ning pains  occur  usually  in  those  patients  who  have  many 
foci  of  infection,  and  they  can  often  be  reduced  or  re- 
markably relieved  by  removal  of  all  such  foci. 

Chronic  sepsis  probably  takes  no  part  in  the  patho- 
genesis  of  tabes  dorsalis  except  as  that  of  an  unrelated 
infection  which  favors  the  advance  of  the  specific  proc- 
ess. All  of  the  patients  on  whom  observations  were 
made  gave  positive  Wassermann  tests  before  and  after 
the  removal  of  focal  infections,  and  the  changes  observed 
in  the  spinal  fluid  did  not  differ  strikingly  from  those 
which  might  have  been  expected  to  follow  the  antisyph- 
ilitic  measures  which  were  employed. 


84  ORAL   SEPSIS 

Removal  of  focal  infections  as  part  of  the  regime  in 
the  treatment  of  syphilis  is  also  of  value  in  facilitating 
the  use  of  mercury  and  potassium  iodide  and  in  render- 
ing their  use  less  harmful.  Mercury  and  potassium 
iodide  in  therapy  exert  an  unfavorable  influence  upon  in- 
fections in  the  alveolar  process  and  in  the  throat  and  ap- 
parently also  on  pyogenic  infection  in  other  localities. 
In  many  instances  they  cause  trivial  infections  to  develop 
rapidly  and  give  rise  to  definite  toxemias.  It  is  impos- 
sible to  push  mercury  and  potassium  iodide  to  the  physio- 
logic limit  in  the  face  of  severe  oral  sepsis  or  badly  in- 
fected tonsils  without  increasing  the  local  trouble  and 
rendering  the  systemic  effect  of  the  infections  more  seri- 
ous.- Many  of  the  untoward  effects  of  mercury  and 
potassium  iodide  are  without  question  due  to  their  ac- 
tion in  stirring  up  the  latent  infection.  For  this  reason 
the  radical  treatment  of  oral  sepsis  with  the  aid  of 
roentgenograms,  the  removal  of  infected  tonsils,  and  all 
other  infections  is  strongly  indicated  as  an  adjunct  to 
the  treatment  of  syphilis.  When  this  is  done,  mercury 
and  potassium  iodide  pushed  to  the  physiologic  limit  ap- 
pear to  be  relatively  harmless. 


CHAPTER  VI 
TOXIC  EFFECT  OF  ORAL  SEPSIS 

A  true  toxin  is  not  formed  by  any  of  the  organisms 
which  ordinarily  take  part  in  the  pathology  of  oral  sepsis. 
Killed  cultures  of  the  organisms,  or  extracts  of  the  or- 
ganisms, or  the  culture  media  in  which  they  have  grown 
may  be  injected  in  large  quantities  into  healthy  guinea 
pigs  without  immediate  gross  ill  effect.  These  organisms 
differ  strikingly  in  this  respect  from  tetanus  and  diph- 
theria bacilli,  each  of  which  produces  a  true  toxin  which 
is  poisonous  in  high  degree  even  when  administered  sub- 
cutaneously  to  animals  in  very  minute  doses.  The  prod- 
ucts formed  by  certain  organisms  which  inhabit  the 
mouth  may  be  extremely  toxic,  however,  through  an  en- 
tirely different  mechanism;  namely,  through  the  devel- 
opment in  an  individual  of  a  condition  known  as  allergy. 
This  term,  introduced  by  von  Pirquet,  is  used  to  desig- 
nate the  changed  condition  of  humans  or  animals  caused 
by  infectious  diseases  or  produced  by  inoculation  with 
alien  proteins  which  causes  the  individual  to  react  in  a 
peculiar  way  if  the  bacteria  responsible  for  the  infectious 
disease  or  if  the  protein  with  which  he  may  have  been 
inoculated  is  reintroduced  into  the  circulation.  The  en- 
suing reaction  is  in  some  respects  protective  and  bene- 
ficial, but  in  other  respects  it  may  be  harmful  and  even 
dangerous. 

Allergy  and  its  effects  are  well  illustrated  by  the  ac- 
tion of  tuberculin.  Killed  tubercle  bacilli  or  their  ex- 
tracts, or  media  in  which  tubercle  bacilli  have  grown  may 
be  injected  in  large  amounts  into  normal  untreated  ani- 
mals without  gross  immediate  ill  effect.  If  even  minute 
quantities  be  injected  into  animals  or  individuals  with 

85 


86  ORAL    SEPSIS 

tuberculosis,  however,  the  effect  is  entirely  different. 
Instead  of  its  being  apparently  inert,  it  causes  a  reaction 
which  may  result  quickly  in  death.  The  changed  con- 
dition of  the  animal  produced  by  the  tuberculous  infec- 
tion which  renders  it  sensitive  to  the  products  of  the 
tubercle  bacillus  is  the  condition  known  as  allergy.  Sev- 
eral striking  phenomena  follow  the  introduction  of  tuber- 
culin into  tuberculous  individuals  or  animals  which  never 
appear  in  the  nontuberculous.  These  are:  first,  pain, 
swelling,  redness,  and  sometimes  necrosis,  at  the  site  of 
the  inoculation ;  second,  a  rise  of  temperature  and  pulse 
rate  and  general  symptoms  of  toxemia;  third,  inflam- 
matory changes  at  the  site  of  all  active  tuberculous  le- 
sions. This  last  phase  of  reaction  may  be  slight  or  may 
be  well  marked.  It  may  hasten  the  breaking  down  of 
tuberculous  tissue  and  lead  to  rapid  spread  of  the  disease. 

Some  individuals  with  tuberculosis  become  so  sensi- 
tive to  products  of  the  tubercle  bacillus  that  amounts  of 
tuberculin  as  minute  as  one  one-thousandth  of  a  milli- 
gram are  sufficient  to  produce  severe  reactions.  Others 
tolerate  larger  amounts. 

A  reaction  as  above  described  can  be  produced  in 
tuberculous  animals  by  the  subcutaneous  injection  of  liv- 
ing tubercle  bacilli  as  well  as  by  extracts  of  the  organ- 
isms. If  tuberculous  guinea  pigs  are  inoculated  with 
living  tubercle  bacilli,  a  local  and  general  reaction  re- 
sults similar  in  its  essentials  to  the  reaction  produced  by 
extracts  of  dead  bacilli.  If  a  localized  tuberculous  lesion 
in  humans  (such  as  a  tuberculous  joint)  is  subjected  to 
massage  and  manipulation,  living  tubercle  bacilli  and 
their  products  gain  entry  into  the  circulation  and  a  transi- 
tory rise  of  temperature  and  other  symptoms  of  reaction 
follow. 

The  above  well-known  facts  regarding  tuberculous  in- 
fection and  the  sensitization  produced  by  it  are  true  of 
infections  in  general.  An  attack  of  typhoid,  for  example, 


TOXIC  EFFECT  OF  ORAL  SEPSIS  87 

renders  an  individual  sensitive  to  the  protein  of  the 
typhoid  bacillus,  an  attack  of  furunculosis  renders  one 
sensitive  to  the  staphylococcus  aureus,  etc.,  so  that  indi- 
viduals having  these  diseases  usually  show  a  local,  gen- 
eral, and  focal  reaction  if  they  are  inoculated  with  killed 
cultures  of  the  offending  bacteria.  This  may  temporarily 
increase  the  inflammatory  processes,  the  severity  of 
which  would  appear  to  depend  to  a  certain  extent  upon 
the  quantity  of  bacteria  injected. 

Individuals  with  chronic  furunculosis  react  and  show 
temporary  exacerbation  of  the  disease,  not  only  when  in- 
oculated with  an  excessive  quantity  of  killed  staphylo- 
cocci,  but  also  when  they  are  subjected  to  the  effect  of 
an  increased  number  of  living  bacteria  due  to  the  devel- 
opment of  a  fresh  furuncle.  This  often  causes  both  a 
general  and  a  focal  reaction.  For  example,  with  the  de- 
velopment of  a  fresh  furuncle  there  may  appear  fever, 
malaise,  etc.  (general  reaction)  and  an  exacerbation  in 
the  inflammatory  process  in  the  healing  furuncles  (focal 
reaction),  in  fact,  signs  of  activity,  such  as  itching,  red- 
ness, etc.,  may  appear  in  the  scars  of  recently  healed 
furuncles.  This  may  be  followed  by  a  discharge  of  pus 
containing  staphylococcus  aureus. 

These  well-known  principles  which  are  true  of  infec- 
tion in  general  are  also  applicable  to  oral  sepsis.  Indi- 
viduals with  dental  sepsis  become  sensitized  to  the  pro- 
tein of  the  infecting  organisms.  The  protein  of  these 
organisms  is  to  them  no  longer  harmless  and  inert,  but 
may  under  certain  circumstances  be  poisonous  to  them. 
The  protein  of  these  organisms  is  thereafter  a  possible 
source  of  systemic  disturbance.  The  sensitization  pro- 
duced is  similar  in  every  way  to  that  observed  in  indi- 
viduals with  tuberculosis,  furunculosis,  etc.,  and  the  re- 
actions which  follow  inoculation  with  killed  bacteria  or 
the  reactions  which  follow  inoculation  with  living  bac- 
teria by  Nature  as  a  result  of  the  development  of  a  new 


88 

infection  are  similar  in  every  respect  to  those  of  the 
foregoing  examples. 

If  an  individual  with  oral  sepsis  develops  an  acute  in- 
fection, such  as  tonsillitis  or  an  acute  alveolar  abscess 
due  to  the  same  organism  which  may  be  infecting  the 
gums,  a  general  reaction  follows,  due  to  the  action  of  the 
protein  of  these  microorganisms  upon  the  sensitized  in- 
dividual. A  focal  reaction  in  the  gums  may  follow  this 
and  may  cause  a  rapid  increase  in  the  inflammatory  proc- 
ess there  localized.  It  is  possible  for  a  focal  reaction  to 
occur  even  in  lesions  of  the  gums  which  have  nearly 
healed  and  in  this  way  cause  recurrence  of  an  apparently 
cured  case  of  pyorrhea.  Focal  infections  such  as  chron- 
ically infected  tonsils,  alveolar  abscesses,  etc.,  often  har- 
bor the  same  organisms  as  infected  gums  and  often 
prevent  permanent  cure  of  oral  sepsis  through  the  ac- 
tivity of  the  bacteria  of  these  localities  giving  rise  to 
repeated  focal  reactions  in  the  gum,  and  in  this  way 
causing  repeated  recurrence  and  extension  of  the  local 
inflammatory  process.  The  permanent  cure  of  oral  sep- 
sis is,  therefore,  often  dependent  on  the  removal  of  all 
other  sources  of  systemic  infection.  (See  Figs.  31  to  36.) 

In  the  previous  paragraph  the  effect  which  coexisting 
infections  may  have  upon  oral  sepsis  has  been  dwelt 
upon.  Oral  sepsis  may  have  an  analogous  effect  upon 
all  chronic  foci  of  infection  located  elsewhere  in  the  body 
which  harbor  the  same  microorganisms;  for  example, 
an  acute  alveolar  abscess  may  cause  a  focal  reaction  in 
a  chronically  infected  tonsil  and  give  rise  to  an  attack 
of  acute  tonsillitis.  Likewise,  it  may  cause  a  focal  re- 
action in  a  chronically  infected  appendix,  gall  bladder  or 
gastric  mucosa  and  give  rise  to  acute  symptoms  of  local 
inflammation.  The  extraction  of  badly  infected  teeth  may 
have  the  same  effect,  and  may  be  followed  in  less  than 
twenty-four  hours  by  a  severe,  acute  inflammatory  re- 
action in  distant  organs  (evidently  a  focal  reaction). 


TOXIC  EFFECT  OF  ORAL  SEPSIS  89 

So  prompt  an  effect  must  be  the  effect  of  a  reaction  in 
the  secondary  focus  followed  by  the  rapid  growth  of  or- 
ganisms already  there  localized  rather  than  to  a  fresh 
acute  metastatic  infection  from  the  alveolar  process. 
The  following  case  illustrating  this  type  of  reaction  is 
cited  as  a  typical  example : 

Patient,  aged  sixty,  relatively  normal  for  her  age,  had 
ten  infected  teeth  extracted.  In  less  than  twenty-four 
hours  after  this  there  developed  a  severe  acute  follicular 
tonsillitis.  The  infection  several  days  later  began  to 
spread  from  the  gums  to  the  cheeks,  pharynx,  and  tongue 
and  gave  rise  to  an  extensive  ulcerative  stomatitis.  A 
point  worthy  of  emphasis  in  this  case  is  the  fact  that 
the  inflammatory  reaction  in  the  tonsils,  while  relatively 
distant  from  the  gums,  preceded  by  several  days  the  in- 
fection of  the  neighboring  tissues  of  the  mouth.  This 
attack  of  acute  tonsillitis  was  analogous  in  every  way 
to  the  acute  inflammatory  reaction  in  the  lungs  which 
may  be  brought  about  in  tuberculous  individuals  by  the 
injection  of  an  overdose  of  tuberculin.  It  is  by  no  means 
uncommon  to  observe  pain  in  the  region  of  the  gall  blad- 
der, appendix,  stomach,  or  joints  a  few  hours  after  the 
extraction  of  teeth,  and  such  may  frequently  be  inter- 
preted as  focal  reactions  caused  by  the  dissemination 
of  microorganisms  or  their  products  from  the  alveolar 
process. 

While  extraction  of  the  infected  teeth  frequently 
causes  acute  reactions  in  infected  organs  and  occasionally 
in  this  way  causes  spread  of  disease,  the  good  eventually 
derived  usually  far  outweighs  the  ill.  Frequently  the 
clinical  manifestations  of  chronic  appendicitis,  cholecyst- 
itis, gastric  and  duodenal  ulcer,  chronic  arthritis,  etc., 
clear  up  rapidly  after  the  extraction  of  teeth  even  though 
the  first  effect  may  have  been  an  increase  in  the  inflam- 
matory processes.  Occasionally  chronic  inflammatory 
conditions  which  appear  rather  urgently  to  indicate  the 


90  ORAL   SEPSIS 

need  of  surgery  clear  up  after  as  simple  a  procedure  as 
the  extraction  of  a  tooth.  Even  more  gratifying  is  the 
relief  occasionally  obtained  in  chronically  inflamed 
organs  which  can  not  be  handled  surgically,  such  as 
chronic  nephritis  and  arythmia. 

Combined  with  chronic  inflammatory  diseases  of  any 
organ  there  frequently  exists  a  functional  disturbance 
in  the  organ  which  appears  out  of  all  proportion  to  the 
gravity  of  the  inflammatory  lesion.  This  is  without  ques- 
tion frequently  the  effect  of  repeated  focal  reaction  in 
the  organ  caused  by  activity  in  some  distant  focus.  It  is 
perhaps  for  this  reason  that  uremia  and  other  symptoms 
of  renal  insufficiency  in  cases  of  chronic  intestinal  ne- 
phritis, cardiac  insufficiency,  and  arhythmia  in  cases  of 
chronic  myocarditis,  etc.,  are  often  relieved  in  a  most 
gratifying  way  by  the  treatment  of  oral  sepsis  or  other 
foci  of  chronic  infection. 

The  sensitization  of  an  infected  individual  against  a 
given  organism  may  be  increased  by  repeated  inocula- 
tions hypodermically  with  the  protein  of  that  organism. 
The  same  procedure  may  produce  tolerance  for  the  or- 
ganism. Whether  the  effect  produced  is  increased  sensi- 
tiveness or  increased  tolerance  is  largely  dependent  upon 
the  rate  at  which  the  inoculations  are  given  and  the  size 
and  rate  of  increase  in  the  dose.  If  the  dose  is  too  large 
or  too  frequently  repeated,  the  sensitiveness  may  be  in- 
creased. If  the  dose  is  not  larger  than  can  be  tolerated 
by  the  individual  and  is  not  repeated  too  frequently,  a 
high  degree  of  tolerance  may.be  gained.  If  tuberculous 
individuals  are  inoculated  with  large  and  rapidly  re- 
peated doses  of  tuberculin,  a  marked  increase  in  sensi- 
tiveness is  produced  and  a  rapid  advance  in  the  disease 
may  follow.  This  practice  in  tuberculin  therapy  has 
given  disastrous  results  in  the  past.  If  tuberculous  indi- 
viduals are  repeatedly  inoculated  with  carefully  gradu- 
ated doses  of  tuberculin  at  appropriate  intervals,  a  tol- 


TOXIC  EFFECT  OF  ORAL  SEPSIS  91 

erance  may  be  developed  which  is  so  great  that  a  quantity 
of  tuberculin  can  eventually  be  given  without  deleterious 
effect  which  is  thousands  of  times  as  great  as  that  which 
would  have  originally  caused  a  reaction.  The  toxic  effect 
of  given  infection  would  seem,  on  the  basis  of  experi- 
mental results  and  the  above  cited  facts,  to  depend  in 
part  upon  the  degree  of  sensitization  in  the  individual, 
in  part  upon  the  degree  of  tolerance  which  had  been  de- 
veloped, and,  finally,  in  part  upon  the  rate  and  regularity 
with  which  the  organisms  and  their  products  gain  entry 
into  the  circulation.  This  explains  the  fact  that  some 
individuals  with  dental  sepsis  show  many  of  its  toxic 
effects  while  others  similarly  infected  show  relatively 
few. 

In  the  preceding  pages  the  toxic  effect  of  bacteria  and 
their  products  upon  infected  tissues  has  been  dwelt  upon. 
The  effect  which  such  products  may  have  upon  uninfected 
tissues  is  perhaps  even  more  interesting,  though  per- 
haps of  less  clinical  importance.  This  effect  can  be  well 
illustrated  by  describing  the  effect  upon  animals  of  alien 
protein  not  of  bacterial  origin. 

It  is  now  well  known  that  normal  untreated  guinea 
pigs  may  be  inoculated  with  large  amounts  of  horse 
serum  or  other  alien  protein  without  apparent  immediate 
ill  effect  and  that  if  this  inoculation  is  repeated  after 
a  period  of  several  weeks,  the  animal  is  likely  to  die  in  a 
short  time  with  a  peculiar  syndrome  of  symptoms  which 
has  been  called  anaphylactic  shock.  The  term  anaphy- 
laxis  was  introduced  by  Richet  who  looked  upon  the  phe- 
nomena fallaciously  as  an  effect  of  a  lack  of  protection. 
The  phenomenon  had  previously  been  observed  by  Ma- 
gendi  and  Theobald  Smith.  Since  then,  Arthus,  Vaughan, 
von  Pirquet,  Eosenau  and  Anderson,  Meltzer,  Auer  and 
Lewis,  and  others  have  added  interesting  observations 
which  have  made  the  subject  one  of  great  general  in- 
terest. The  symptoms  produced  by  treating  sensitized 
animals  with  alien  proteins  vary  in  different  animals, 


92  ORAL   SEPSIS 

vary  with  the  degree  to  which  the  animal  has  been 
sensitized,  and  finally  vary  with  the  nature  and 
quantity  of  the  protein  used.  Guinea  pigs  are  quite 
sensitive  to  the  effect  of  alien  proteins,  and  if  a 
second  dose  is  administered  to  them  after  an  appro- 
priate interval  of  time,  death  often  ensues  as  a  result 
of  bronchiole  constriction  and  asphyxia.  In  other 
animals  different  symptoms  are  dominant  and  often  are 
of  a  relatively  mild  nature.  The  symptoms  which  may 
be  expected  in  animals  in  more  or  less  marked  degree 
are  as  follows :  irritability  followed  by  depression,  pros- 
tration and  often  apparent  paralysis,  dyspnea,  discharge 
of  urine  and  feces,  lowering  of  blood  pressure,  a  rise  or 
lowering  of  body  temperature,  reduction  in  the  leucocyte 
count,  eosinophilia,  delay  in  the  coagulation  time  of  the 
blood,  agglutination  of  the  blood  platelets  with  lowering 
of  the  platelet  count  as  a  result  of  the  larger  clumps 
being  filtered  off  by  the  capillaries,  constriction  of 
the  bronchioles  frequently  giving  rise  to  an  embar- 
rassment of  respiration  which  in  the  more  extreme  cases 
prevents  entirely  the  expulsion  of  air  and  causes  ex- 
treme inflation  of  the  lungs,  contraction  of  nonstriated 
muscle  generally  giving  rise  to  bronchiole  spasm,  in- 
creased peristaltic  movements  in  the  stomach  and  intes- 
tine, emptying  of  bladder  and  rectum,  bloody  diarrhea, 
etc.,  increased  glandular  secretion  especially  of  the  liver, 
pancreas,  lacrimal,  and  salivary  glands,  increased  ir- 
ritability of  the  peripheral  nerves,  etc.  In  humans,  ana- 
phylactic  symptoms  occasionally  follow  the  use  of  thera- 
peutic sera,  vaccines,  etc.  These  are  usually  relatively 
mild  as  compared  with  those  shown  by  sensitized  ani- 
mals. Those  most  frequently  observed  are  urticaria, 
erythema,  angioneurotic  edema,  pain  and  swelling  of  the 
joints,  and  leucopenia.  The  symptoms  in  humans  may 
be  much  more  severe,  however,  and  may  in  some  in- 
stances simulate  the  severe  symptoms  observed  in  ani- 
mals. Very  severe  reactions  are  occasionally  observed 


TOXIC  EFFECT  OF  OEAL  SEPSIS  93 

after  the  use  of  pollen  extracts  in  the  treatment  of  hay 
fever  and  asthma. 

Guinea  pigs,  which  are  highly  sensitive  to  anaphylactic 
shock,  may  be  sensitized  by  minute  quantities  of  a  for- 
eign serum.  One  one-thousandth  milligram  or  less  often 
suffices  to  sensitize  them  to  such  a  degree  that  a  sub- 
sequent injection  of  %o  c-  c-  or  more,  given  after  an  incu- 
bation period  of  two  or  three  weeks,  almost  invariably  re- 
sults in  convulsions,  constriction  of  the  bronchioles  and 
rapid  asphyxia. 

Guinea  pigs  may  be  sensitized  to  alien  protein  by 
methods  other  than  that  of  subcutaneous  inoculation ;  for 
example,  they  can  be  sensitized  by  the  feeding  of  certain 
proteins,  by  the  introduction  of  proteins  through  the 
skin  by  inunction,  through  the  mucous  membranes  of  the 
colon  by  rectal  injection,  through  the  mucous  membrane 
of  the  respiratory  tract  by  the  use  of  sprays,  etc.  In 
fact,  if  an  alien  protein  gains  entry  undigested  into  the 
circulation  or  tissues  in.  any  way,  it  may  sensitize. 

Proteins  vary  in  the  degree  to  which  they  can  sensitize. 
Serums  and  egg  albumens,  for  example,  may  produce  a 
high  degree  of  sensitization,  whereas  bacterial  proteins 
usually  produce  relatively  very  little. 

Protein  sensitization  as  observed  clinically  in  humans 
probably  has  many  sources  of  origin.  It  is  difficult  to 
understand  just  how  the  sensitization  takes  place.  Some 
individuals,  for  example,  become  sensitized  to  the  pro- 
tein of  certain  articles  of  food  (egg,  beef,  strawberries, 
etc.),  some  to  the  pollen  of  plants  (ragweed,  golden  rod, 
etc.),  some  to  animal  odors  (horse,  cat,  guinea  pig,  etc.). 
The  sensitization  may  reach  such  a  degree  that  whenever 
the  individual  comes  in  contact  even  with  minute  amounts 
of  the  protein  to  which  he  is  sensitized  certain  disagree- 
able and  even  dangerous  symptoms  of  anaphylaxis  are 
noticed,  in  fact,  in  many  individuals  almost  infinitesimal 
quantities  of  the  offending  protein  may  produce  severe 


94  ORAL   SEPSIS 

symptoms  of  anaphylaxis.  Individuals  sensitized  to 
horse  albumen  may  show  symptoms  of  anaphylaxis  after 
inhaling  the  infinitesimal  quantity  of  horse  protein  in 
the  air  around  horses.  Individuals  sensitized  to  egg  al- 
bumen may  have  urticaria  after  eating  minute  quantities 
of  egg  albumen.  Individuals  sensitized  against  plant 
pollen  may  have  hay  fever  or  asthma  after  contact  with 
the  minute  quantity  of  pollen  in  the  air.  Severe  anaphy- 
lactic  shock  can  be  produced  in  such  individuals  by  the 
subcutaneous  injection  of  as  small  an  amount  as  one 
one-thousandth  milligram  of  an  extract  of  the  pollen  to 
which  they  are  sensitized. 

The  degree  to  wThich  sensitization  may  develop  in  hu- 
mans is  almost  unbelievable.  I  observed  a  patient  who 
was  so  sensitized  to  cat  protein  that  whenever  she  was  in 
the  room  with  a  cat,  symptoms  of  anaphylaxis  were  no- 
ticed. She  told  friends  of  this  peculiarity.  One  disbeliev- 
ing brought  a  kitten  into  the  house  in  his  pocket  believing 
that  if  the  patient  were  not  aware  of  its  presence,  the 
symptoms  would  not  appear.  The  effect  on  the  patient 
was  such,  however,  as  to  alarm  the  entire  household  and 
convince  the  friend  that  the  experiment  would  not  bear 
repetition.  Kolmer  mentions  an  instance  of  an  indi- 
vidual so  sensitized  against  rabbits,  guinea  pigs,  and 
horses,  that  if  the  air  of  the  room  in  which  these  animals 
were  kept  were  passed  fifteen  minutes  through  lint  and 
the  lint  extracted  with  saline .  solution,  the  application 
of  this  extract  to  the  abraded  skin  of  the  individual 
would  cause  a  marked  local  reaction.  Protein  sensitiza- 
tion acquired  in  nature  as  above  described  is  greater  in 
degree  than  that  produced  experimentally  in  animals  or 
humans  by  the  subcutaneous  injection  of  a  foreign  pro- 
tein. It  is  also  of  longer  duration.  Sensitization  against 
plant  pollen,  for  example,  may  last  for  years,  whereas 
that  produced  artifically  often  diminishes  rapidly  after 
a  few  weeks. 


TOXIC  EFFECT  OF  ORAL  SEPSIS  95 

The  above  examples  which  show  the  effect  which  may 
be  produced  in  sensitized  humans  and  animals  by  mi- 
nute quantities  of  an  alien  protein  are  mentioned  for 
the  purpose  of  illustrating  the  extreme  and  diversified 
effect  which  may  be  produced  under  certain  circum- 
stances by  small  amounts  of  protein  which  to  nonsensi- 
tive  individuals  are  practically  harmless.  In  pyorrhea 
pockets  and  alveolar  abscesses  the  tissues  of  the  human 
come  in  intimate  contact  with  alien  proteins  and  split 
proteins  of  many  types  and  sources  due  to  the  activity  of 
bacteria,  protozoa,  etc.  The  individual  is  not  protected 
from  the  absorption  of  these  by  an  intact  epithelial  mem- 
brane. It  seems  reasonable  to  presume  that  these  occa- 
sionally gain  entry  into  the  tissues  and  blood  and 
sensitize  the  individual  in  high  degree  and  by  virtue 
of  this  become  possible  sources  of  anaphylactic  phe- 
nomena. Whereas  bacterial  proteins  are  not  prone 
to  cause  the  so-called  anaphylactic  phenomena  experi- 
mentally, the  fact  that  such  may  occur  as  an  effect  of 
bacterial  products  has  been  shown  by  the  researches 
of  Baldwin  and  Krause  who  working  with  the  protein 
of  the  tubercle  bacillus  were  able  to  produce  in  animals 
all  the  striking  anaphylactic  phenomena  observed  experi- 
mentally after  the  use  of  serums.  In  harmony  with  this 
is  the  well-known  fact  to  be  dwelt  upon  later  that  typical 
severe  anaphylactic  phenomena  frequently  complicate 
acute  infectious  diseases,  such  as  rheumatic  fever,  ton- 
sillitis, etc. 

The  work  of  Major  is  interesting  in  this  connection. 
Working  with  doses  of  alien  protein  which  were  too  small 
to  cause  visible  anaphylactic  phenomena  in  animals,  he 
was  able  to  produce  profound  metabolic  disturbance  and 
extreme  emaciation  believed  to  be  due  to  a  chronic  ana- 
phylactic state  too  mild  to  give  rise  to  the  usual  visible 
manifestations  of  the  condition.  His  inference  drawn 
from  the  experiments  that  metabolic  disturbances  ob- 


96 

served  clinically  are  often  the  result  of  a  chronic  mild 
anaphylactic  state  is  in  harmony  with  the  fact  that  in- 
dividuals often  gain  weight  and  strength  after  the  treat- 
ment of  chronic  infections. 

Numerous  theories  have  been  offered  to  explain  pro- 
tein sensitization.  Those  suggested  by  Vaughan,  von 
Pirquet,  and  Wolff-Eisner  are  similar  in  the  essential 
that  it  is  assumed  that  an  animal  under  the  influence  of 
an  alien  albumen  develops  enzymes  which  break  it  down 
and  that  the  split  products  which  result  are  poisonous 
and  cause  symptoms  of  intoxication.  Vaughan,  after  ex- 
haustive experimentation  in  this  field,  developed  an  elab- 
orate theory  which,  as  he  suggests,  may  prove  false  in 
some  respects,  but  which  serves  well  the  purposes  of  a 
working  hypothesis.  It  is  hardly  possible  in  a  work  so 
brief  as  this  one  to  go  into  the  various  details  of  the  in- 
teresting and  ingenious  views  of  Vaughan,  von  Pirquet, 
Jobling,  Novi,  and  others.  For  this,  the  reader  is  re- 
ferred to  the  original  contributions  of  these  observers. 
(See  Bibliography.) 

A  summary  of  the  theories  which  have  received  most 
general  acceptance  is  as  follows:  Albuminous  mate- 
rials taken  as  food  are  broken  down  into  simpler  com- 
pounds in  the  gastrointestinal  tract  by  digestive  enzymes 
and  are  rebuilt  into  the  complex  protein  molecule  dur- 
ing and  after  absorption.  The  protein  molecule  thus 
built  up  is  distinctive  for  each  species  of  animal.  If  the 
albuminous  material  of  one  species  of  animal  gains  entry 
into  the  circulation  of  another  species  without  first  be- 
ing broken  down  by  the  digestive  enzymes  of  the  animal 
receiving  it  and  then  being  rebuilt  into  its  distinctive 
type  of  protein,  the  animal  receiving  it  becomes  sensi- 
tive to  the  protein  of  that  particular  species  and  remains 
so  for  a  period  of  weeks  or  months  or  years.  If,  during 
this  period  of  sensitization,  the  protein  to  which  the  ani- 
mal has  been  sensitized  is  introduced  into  the  circulation 


TOXIC  EFFECT  OF  ORAL  SEPSIS  97 

in  sufficient  quantity,  the  animal  may  die  in  a  few  minutes 
of  anaphylactic  shock.  If  the  animal  survives,  the  symp- 
toms of  anaphylaxis  usually  disappear  after  a  few  hours. 
If  the  protein  gains  entry  into  the  circulation  in  smaller 
quantity  and  repeatedly,  the  symptoms  may  be  milder 
and  simulate  those  observed  as  a  result  of  acute  or  chronic 
infection. 

It  has  been  suggested  that  sensitization  is  due  to  the 
development  of  enzymes  in  the  tissues  of  an  animal  for 
the  purpose  of  destroying  the  foreign  protein  and  that  in 
breaking  it  down  certain  split  products  are  formed  which 
may  be  toxic  and  cause  the  severe  symptoms  observed  in 
anaphylactic  shock.  The  enzymes  wilich  are  developed 
under  the  influence  of  a  foreign  undigested  albumen  are 
apparently  remarkably  specific  and  are  able  to  digest 
only  the  type  of  protein  which  called  them  forth.  The 
acquired  faculty  of  animal  tissues  to  furnish  enzymes 
which  are  able  to  destroy  alien  protein  of  certain  types 
and  in  so  doing  to  liberate  products  which  are  poisonous 
to  the  animal  constitutes  the  condition  known  as  sen- 
sitization. The  result  of  this  is,  that  whenever  a  foreign 
protein  to  which  an  animal  has  become  sensitized  comes 
in  contact  with  its  tissues,  it  is  broken  down  rapidly  by 
its  enzymes  with  the  liberation  of  poisonous  split  prod- 
ucts. If  these  are  formed  in  quantity  larger  than  the 
animal  can  tolerate,  the  symptoms  of  anaphylaxis  of 
varying  severity  result.  As  mentioned  by  Vaughan,  the 
above  conclusions  may  prove  false  in  some  respects,  but 
at  present  serve  the  purposes  of  a  working  hypothesis. 
Other  ingenious  theories  have  been  suggested,  but  it  is 
hardly  possible  in  this  space  to  discuss  them. 

Tolerance  for  alien  proteins  may  be  developed  in  sen- 
sitized animals  just  as  tolerance  against  tuberculin  may 
be  developed  by  tuberculous  individuals.  If  an  animal 
sensitized  to  horse  albumen  is  given  subcutaneously  a 
dose  of  horse  serum  which  produces  an  anaphylactic  re- 


98  OKAL   SEPSIS 

action  but  which  does  not  cause  death,  the  animal  be- 
comes refractory  for  a  certain  period  of  time.  Inocula- 
tion with  horse  serum  during  such  a  period  has  less  than 
its  usual  deleterious  effect.  Tolerance  for  a  given  pro- 
tein may  be  enormously  increased  in  a  sensitized  animal 
or  individual  by  giving  subcutaneously  graduated  doses 
of  the  protein  at  appropriate  intervals.  Upon  this  prin- 
ciple depend  the  good  results  obtained  in  the  treatment 
of  hay  fever  with  graduated  doses  of  pollen  extract  and 
of  horse  asthma  with  graduated  doses  of  horse  protein. 

Anaphylaxis  as  produced  experimentally  by  animal  in- 
oculation is  usually  acute  and  of  relatively  short  dura- 
tion. Anaphylaxis  as  observed  clinically  in  humans, 
however,  is  often  chronic  and  of  a  milder  nature;  for 
example,  bronchial  asthma,  first  mentioned  by  Meltzer  as 
an  anaphylactie  phenomenon,  may  continue  for  months, 
in  fact  may  continue  so  long  as  the  individual  comes  in 
contact  with  the  protein  to  which  he  is  sensitized.  Also 
urticaria  due  to  sensitization  against  egg  albumen  may 
continue  for  months  or  years  unless  the  individual  ex- 
cludes egg  from  his  diet. 

As  previously  mentioned,  bacterial  proteins  are  not 
prone  to  cause  anaphylactic  phenomena  upon  injection 
into  sensitized  animals.  Anaphylaxis  may,  without  ques- 
tion, occur  in  humans,  however,  as  a  result  of  infection ; 
for  example,  angioneurotic  edema,  urticaria,  and  eryth- 
ema, and  certain  eczemas  unquestionably  anaphylactic 
in  nature  occasionally  occur  during  an  attack  of  acute 
articular  rheumatism,  tonsillitis  and  other  infectious  dis- 
eases. Such  phenomena  are  occasionally  observed  also 
in  association  with  chronic  foci  of  infection  such  as  chron- 
ically infected  tonsils  and  alveolar  abscesses  and  the 
same  may  clear  up  immediately  or  soon  after  the  offend- 
ing foci  are  removed. 

The  problem  of  interest  in  this  connection  is  not  the 
question  whether  or  not  oral  sepsis  is  a  possible  cause 


TOXIC  EFFECT  OF  ORAL  SEPSIS  99 

of  anaphylactic  phenomena,  for  one  is  safe  in  assuming 
that  this  is  so.  The  question  of  interest  is  whether  or 
not  oral  sepsis  is  a  frequent  source  of  anaphylactic  phe- 
nomena, and  whether  or  not  this  is  a  factor  of  clinical 
importance  in  the  causation  of  functional  or  organic  dis- 
ease. The  fact  that  the  areas  of  sepsis  are  small  is  not 
inimical  to  the  assumption  that  such  is  the  case,  for 
severe  anaphylactic  reactions  may  be  caused  by  traces 
of  a  foreign  protein.  The  fact  that  it  is  probably  a 
relatively  frequent  and  important  source  seems  likely 
from  the  fact  that  oral  sepsis  is  a  chronic  disorder  of 
years'  duration.  It  harbors  organisms  of  many  types 
and  finds  the  body  repeatedly  in  varying  states  of  sen- 
sitization  and  tolerance. 

According  to  the  views  of  Vaughan,  alien  proteins  have 
affinities  for  certain  tissues  just  as  do  certain  strains  of 
bacteria,  and  exert  their  toxic  effect  chiefly  upon  the 
tissues  with  which  they  combine.  Whether  the  effect  be 
one  of  functional  disturbance  or  of  demonstrable  organic 
lesion  would  appear  to  depend  upon  the  severity  and 
duration  of  the  intoxication.  Just  how  great  a  factor 
such  toxic  albumens  derived  from  the  alveolar  process 
are  in  themselves  a  cause  of  organic  changes  in  normal 
uninfected  tissues  is,  of  course,  a  matter  of  conjecture. 
It  seems  to  be,  however,  a  frequent  cause  of  functional 
disorder.  The  following  symptoms,  which  are  rather  dif- 
ficult to  classify,  appear  frequently  to  be  a  result  in  part 
at  least  of  protein  intoxication  and  often  can  be  relieved 
by  the  removal  of  infected  teeth  or  of  other  sources  of 
chronic  infection. 

General  symptoms,  such  as  nervousness,  malaise,  diz- 
ziness, drowsiness,  inability  to  concentrate,  inexplainable 
weakness,  prostration  after  slight  mental  or  physical  ex- 
ertion, headache  made  worse  by  eyestrain,  or  mental  or 
physical  exertion,  slight  fever  or  subnormal  temperature, 
slight  tachycardia  or  bradycardia,  instability  of  the  vaso- 


100  ORAL    SEPSIS 

motor  center,  etc.,  are  produced  occasionally  in  sensi- 
tized individuals  by  the  use  of  vaccines  made  from  cul- 
tures taken  from  infected  gums  and  are  often  markedly 
relieved  by  the  treatment  of  chronic  infections. 

Angioneurotic  edema,  urticaria,  erythema  nmltiforme, 
and  certain  types  of  eczema,  according  to  Sutton,  may 
be  anaphylactic  in  origin  and  often  clear  up  rapidly  af- 
ter the  removal  of  periodontal  or  other  chronic  infec- 
tions. We  have  observed  each  of  the  above  mentioned 
lesions  appear  during  treatment  with  autogenous  vac- 
cines and  pollens  and  disappear  as  soon  as  treatment  was 
discontinued. 

Disturbances  in  the  function  of  organs  supplied  by  the 
vegetative  nervous  system  are  frequently  observed  as  a 
result  of  oral  sepsis.  Pottenger  has  observed  both  vago- 
tonic  symptoms  and  symptoms  due  to  hypertonus  in  the 
sympathetic  system  as  a  result  of  chronic  tuberculosis, 
the  former  being  the  more  common  in  latent  cases.  The 
disturbances  most  commonly  observed  as  a  result  of  oral 
sepsis  simulate  the  vagotonic,  and  may  give  rise  when 
combined  with  other  contributing  factors  to  such  condi- 
tions as  asthma,  motor  and  secretory  neuroses  of  the 
stomach  and  intestine,  such  as  gastric  hyperacidity,  hy- 
perperistalsis  and  spasticity,  mucous  colitis,  chronic 
diarrhea,  spastic  constipation,  etc.,  functional  disturb- 
ances of  the  kidney,  bladder,  and  sexual  organs.  Such 
conditions  often  clear  up  rapidly  after  the  treatment  of 
chronic  infection  foci. 

Combined  with  organic  disease  in  any  organ,  there  may 
be  functional  disturbance  which  is  out  of  all  proportion 
to  the  gravity  of  the  anatomic  lesion.  Emotions,  abnor- 
mal reflexes,  or  intoxications  of  various  sorts,  anaphy- 
laxis,  etc.,  may  add  greatly  to  disordered  function  in 
any  organ.  Often  symptoms  of  organic  disease  are  made 
worse  by  products  absorbed  from  chronic  areas  of  in- 
fection such  as  oral  sepsis,  and  perhaps  it  is  for  this 


TOXIC  EFFECT  OF  ORAL  SEPSIS  101 

reason  the  symptoms  of  organic  disease,  which  may  or 
may  not  be  infectious  in  origin,  are  often  strikingly  ame- 
liorated by  the  treatment  of  infections  which  may  bear  no 
apparent  relation  to  them.  The  symptoms  of  exophthal- 
mic goiter,  renal  insufficiency,  uremia,  Addison's  disease, 
epilepsy,  chronic  myocardial  insufficiency,  cardiac  arhyth- 
mia,  arterial  hypertension,  etc.,  are  often  benefited  in 
marked  degree  by  the  proper  handling  of  chronic  in- 
fections. 

Finally,  as  previously  mentioned,  oral  sepsis  or  chronic 
infection  from  any  source  may  exert  an  untoward  influ- 
ence upon  the  course  of  other  nonrelated  infections  and 
increase  the  functional  disturbance  caused  by  them. 
Acne,  furunculosis,  general  paresis,  tabes  dorsalis,  tuber- 
culosis, etc.,  are  often  more  amenable  to  treatment  and 
their  systemic  effect  is  less  marked  if  all  nonrelated 
sources  of  infection  are  given  the  attention  they  deserve. 

Oral  sepsis  as  a  source  of  systemic  intoxication  is  not 
the  cause  of  all  ills.  It  is,  however,  a  direct  cause  of  many 
ills,  and  also  frequently  adds  to  the  ill  effect  of  other 
diseases. 


CHAPTER  VII 
HEADACHE  BELATED  TO  ORAL  SEPSIS 

Chronic  infections,  especially  those  in  the  alveolar 
process  are  relatively  frequent  causes  of  chronic  head- 
ache. Many  individuals  who  have  headache  after  eye- 
strain  may  discard  their  glasses  after  the  treatment  of 
chronic  infection.  This  is  not  apparently  due  to  a 
relationship  between  infection  and  eyestrain,  but  rather 
to  the  fact  that  eyestrain  which  so  frequently  figures 
in  the  etiology  of  headache  is  not  always  a  primary  or 
sole  cause,  but  often  is  simply  a  contributory  cause. 
Oral  sepsis,  infected  tonsils,  infected  ethmoids,  hy- 
peracidity due  to  chronic  appendicitis  or  gallstones 
are  directly  or  remotely  the  cause  of  headache  more 
often  perhaps  than  eyestrain.  Defective  teeth  may  be 
responsible  for  headache  in  several  different  ways. 

First,  they  may  be  sources  of  arthritis  in  the  cervical 
spine,  of  myositis  in  the  muscles  of  the  neck,  or  of  in- 
flammatory processes  in  the  bursae,  in  the  tendon  sheaths, 
or  at  the  points  of  attachment  of  the  tendons  to  the  skull 
and  cervical  vertebrae.  All  the  above  may  give  rise  to 
pain  in  the  back  of  the  neck  reflected  upward  over  the 
skull.  This  type  of  headache  is. common  in  individuals 
with  postural  defects, — the  abnormal  strain  on  the  mus- 
cles, tendons,  and  ligaments  of  the  neck  being  a  factor 
perhaps  in  determining  this  localization  for  an  arthritis. 
Such  headaches  may  be  constant  for  days,  may  be  made 
worse  or  brought  on  by  mental  or  physical  exertion, 
fatigue,  excitement,  worry,  eyestrain,  indulgence  in  alco- 
hol; in  fact,  by  any  condition  which  may  act  as  an  addi- 
tional strain  on  the  individual.  The  pain  may  be  so 
severe  as  to  interfere  with  business  activity  or  pleasure. 

102 


HEADACHE  RELATED  TO  ORAL  SEPSIS 


103 


When  headache  such  as  the  above  has  its  origin  in  oral 
sepsis  or  other  infections,  relief  can  often  be  secured  by 
their  treatment.  If  the  condition  is  of  long  standing, 
and  a  considerable  degree  of  rigidity  of  the  cervical 
spine  has  resulted,  the  immediate  effect  is  not  so 
striking.  Apparently  headaches  giving  symptoms  such 
as  those  above  described  may  be  the  result  solely  of  a 
toxic  effect  of  sepsis,  at  least,  it  is  frequently  not  pos- 
sible even  in  cases  of  headache  of  years'  duration  to 
demonstrate  by  physical  examinations  or  by  x-ray,  the 
usual  manifestations  of  local  inflammatory  processes  at 
the  base  of  the  skull  or  in  the  cervical  vertebrae.  The  fol- 


Fig.   166. 


Fig.  167. 


Figs.  166-167. — Roentgenograms  showing  broaches  which  had  been  introduced 
with  ease  through  the  root  canal  and  alveolar  process  practically  as  far  down  as  the 
dental  nerve.  It  shows  the  case  with  which  infection  and  pressure  from  an  alveolar 
abscess  can  be  transmitted  to  the  dental  nerve  and  cause  neuritis  or  neuralgia. 

lowing  case  is  cited  as  a  typical  example  of  headache  due 
primarily  to  dental  sepsis. 

Patient,  female,  age  twenty-five,  had  for  five  years 
been  subject  to  headache  starting  in  back  of  neck  and 
radiating  over  the  skull,  lasting  usually  for  several  days 
at  a  time  and  often  being  so  severe  as  to  render  patient 
incapable  of  mental  or  physical  exertion.  Such  attacks 
could  be  brought  on  by  exertion,  eyestrain,  fatigue,  by 
the  use  of  alcohol,  or  by  indigestion.  The  condition  was 
definitely  alleviated  by  the  removal  of  the  tonsils.  Later 


ORAL    SEPSIS 


several  root  abscesses  were  discovered  and  treatment  of 
these  was  advised.  The  treatment  of  each  abscess  was 
followed  by  such  severe  headache  as  to  confine  the  pa- 
tient to  bed  (probably  a  focal  reaction).  Since  comple- 
tion of  dental  work,  however,  the  patient  has  been  com- 
pletely relieved. 

Second,  oral  sepsis  may  be  a  source  of  neuralgia  or 
neuritis  in  any  or  all  of  the  branches  of  the  facial  nerve. 


Fig.    168. 


Fig.   169. 


Fig.  168. — Case  of  severe  headache  due  to  cervical  arthritis  and  myositis  which 
was  completely,  and  apparently  permanently  relieved  by  the  extraction  of  the  tooth 
shown  in  the  above  roentgenogram. 

Fig.  169. — Case  of  severe  facial  neuralgia  relieved  by  extraction  of  the  tooth 
shown  in  the  above  roentgenogram. 

Fig.  170. — Case  of  headache  due  to  antrum  infection,  the  source  of  which  was 
an  abscess  at  the  root  of  a  bicuspid  tooth.  A  probe  could  be  introduced  into  the 
antrum. 

Tic  douloureux  is  not  included  here,  since  this  condition 
occurs  frequently  in  individuals  whose  teeth  have  all 
been  extracted. 

Third,  headache  is  occasionally  a  referred  toothache. 
Frequently  a  patient  not  only  fails  to  localize  the  par- 


HEADACHE    RELATED    TO    OTCAL    SEPSIS  105 

ticular  tooth  which  causes  pain,  but  occasionally  can  stato 
simply  that  the  pain  is  localized  somewhere  in  the  head. 
Such  a  toothache  may  be  so  severe  as  to  suggest  brain 
tumor.  A  tooth  need  not  be  abscessed  to  cause  such  pain 
and  occasionally  can  be  found  only  after  a  most  careful 
examination  by  a  dentist.  The  following  is  an  example 
of  such  a  case : 

Patient,  male,  age  forty-three,  complained  of  a  con- 
stant and  severe  headache  of  about  three  weeks'  dura- 
tion. It  interfered  with  sleep  and  caused  loss  of  weight 
and  was  at  times  so  severe  as  to  cause  the  patient  to  cry 
out.  Physical,  laboratory,  and  roentgen  examinations 
were  negative  throughout  except  for  disclosing  a  pulp 
stone  in  a  first  upper  molar  tooth.  This  tooth  on  ex- 
amination by  Dr.  R.  M.  Siebel  showed  the  pulp  of  one 
root  to  be  diseased.  Two  of  the  roots  were  vital.  The 
tooth  was  cocainized  and  the  pain  disappeared  immedi- 
ately. Following  extraction  of  the  tooth,  the  headache 
was  permanently  relieved. 

Fourth,  an  alveolar  abscess  may  rupture  into  the  an- 
trum  of  Highmore  and  cause  headache.  The  local  symp- 
toms may  be  so  slight  as  to  escape  notice  entirely.  The 
following  is  a  typical  example: 

Patient,  woman,  age  forty,  had  been  subject  to  head- 
aches since  about  the  age  of  eighteen,  at  which  time  a 
bicuspid  tooth  had  been  devitalized.  Headache  resisted 
all  therapeutic  measures  except  the  strongest  sedatives. 
Examination  showed  an  abscessed  bicuspid  tooth.  When 
the  tooth  was  extracted  a  probe  could  be  introduced  into 
the  antrum.  Following  the  extraction  of  the  tooth,  there 
was  a  marked  exaggeration  of  the  headache  for  some 
time,  and  a  profuse  nasal  discharge  evidently  due  to  an 
exacerbation  of  the  antrum  infection.  Following  this, 
treatment  was  directed  to  the  diseased  antrum,  and  since 
then  the  patient  has  been  relatively  free  from  headache. 


CHAPTER  VIII 
SUMMARY  AND  CONCLUSIONS 

It  has  been  the  purpose  in  this  volume  to  assemble 
facts  which  show  the  many  ways  in  which  chronic 
sepsis  of  any  variety  may  be  a  source  of  systemic 
ill,  and  that,  of  all  chronic  active  infections,  those 
which  occur  at  the  roots  of  the  teeth  are  perhaps  the  most 
common.  The  development  of.  this  knowledge  marks  a 
great  practical  advance  in  the  diagnosis  and  treatment 
of  disease.  It  is  now  apparent  that  many  disorde-rs, 
which  in  previous  years  were  considered  obscure  in  origin 
and  incurable,  are  due  wholly  or  in  part  to  chronic  in- 
fection, and  that  such  diseases  can  often  be  cured  or 
retarded  in  their  progress  by  removal  of  the  primary 
source  of  infection.  It  is  also  apparent  that  the  occur- 
rence of  chronic  sepsis  is  far  more  frequent  than  was 
formerly  supposed.  It  is  so  frequent,  in  fact,  that  few 
of  mature  age  are  wholly  free  from  it. 

Tabulations  of  one  thousand  medical  cases  which  we 
have  examined  in  consulting  office  practice  on  account  of 
miscellaneous  systemic  complaints  gave  the  following  re- 
sults :  Sources  of  chronic  or  frequently  recurrent  infec- 
tion were  found  in  ninety-seven  per  cent  (this  included 
nctive  tuberculosis,  syphilis,  chronic  gastrointestinal  dis- 
orders due  to  abnormalities  in  the  appendix,  gall  bladder, 
to  gastric  and  duodenal  ulcer,  extreme  ptosis,  adhesions, 
chronic  infection  in  the  respiratory  genitourinary  tract, 
etc.).  A  marked  degree  of  oral  sepsis  was  found  in  roent- 
genograms  in  66  per  cent.  In  34  per  cent  either  none  was 
found  or  the  amount  was  so  slight  that  many  would  con- 
sider it  negligible  from  the  standpoint  of  systemic  ill. 
Diseased  tonsils  appeared  to  be  possible  sources  of 

106 


SUMMARY   AND    CONCLUSIONS  107 

disease  in  a  large  percentage  of  cases.  Sixteen  per  cent 
of  the  cases  gave  a  history  of  chronic  nasal  discharge  or 
showed  deviation  of  the  septum,  spurs,  polypi,  or  other 
abnormal  conditions  in  the  nose.  In  a  relatively  small 
percentage  of  these  there  was  tenderness  over  the  frontal 
or  ethmoid  sinuses  or  abnormal  opacities  in  the  region  of 
the  sinuses  disclosed  by  x-ray.  Sixteen  per  cent  of  the 
cases  had  digestive  disturbance  or  other  symptoms 
associated  with  tenderness  in  the  right  iliac  fossa.  A 
minority  of  these  were  thought  to  have  an  abnormal  ap- 
pendix. Seven  per  cent  had  symptoms  which  appeared 
to  be  attributable  to  the  gall-bladder.  In  addition 
a  relatively  large  percentage  had  digestive  disturb- 
ance due  to  either  appendix  or  gall-bladder  disease, 
which  could  not  bo  definitely  diagnosed,  or  to  adhesions, 
extreme  ptosis,  gastric  or  duodenal  ulcer,  etc.  Eleven 
per  cent  gave  positive  Wassermann  tests.  (Bloods  sent 
in  because  of  suspected  syphilis  were  excluded  from  these 
statistics.)  In  over  half  of  these  (6  per  cent  of  the  total 
number  of  cases  examined)  syphilis  of  the  central  ner- 
vous system  was  suspected  clinically  and  verified  by 
lumbar  puncture.  In  7  per  cent  the  presence  of  active 
tuberculosis  was  positively  demonstrated.  A  miscellane- 
ous group  of  infections  was  found  in  a  large  number  of 
cases.  The  great  majority  of  cases  had  more  than  one 
chronic  infection.  Of  the  66  per  cent  having  a  consider- 
able degree  of  oral  sepsis,  72  per  cent  had  other  chronic 
infections  in  addition.  In  but  18  per  cent  was  oral  sepsis 
the  only  active  infection  found. 

The  frequent  occurrence  of  oral  sepsis,  the  frequency 
with  which  other  infections  coexist  and  the  frequency 
with  which  patients  give  a  history  of  having  had  one  or 
more  of  the  more  severe  acute  infectious  diseases,  make 
it  difficult  or  impossible  from  statistics  alone  to  de- 
termine the  exact  role  which  oral  sepsis  plays  in  the 
etiology  of  systemic  disease.  It  is  interesting,  how- 


108  ORAL    SEPSIS 

ever,  to  compare  the  statistics  of  Tlioina  with  those  lie  re 
presented.  In  examining  patients  in  the  Robert  B.  Brig- 
ham  Hospital,  where  practically  all  the  inmates  are  suf- 
ferers from  chronic  disease,  Thoma  found  alveolar  ab- 
scesses in  88  per  cent.  This  ratio  is  higher  than  that 
which  we  found  to  have  oral  sepsis  in  marked  degree  (66 
per  cent)  in  ambulatory  patients  observed  in  office  prac- 
tice. E.  E.  Irons  reports  that  of  124  cases  examined  with 
miscellaneous  diseases,  44  per  cent  had  alveolar  abscesses. 
Of  these  the  arthritic  growth  showed  abscesses  in  76  per 
cent.  Of  the  nephritic  and  cardiovascular  group  47  per 
cent  had  abscesses.  Of  the  miscellaneous  group,  not 
rheumatic  in  origin,  only  23  per  cent  had  oral  sepsis. 
This  is  less  than  one-third  the  percentage  found  in  the 
arthritic  group. 

Among  individuals  examined  by  A.  D.  Black,  without 
reference  to  complaint,  the  percentage  of  periodontal  in- 
fections was  56  for  persons  under  twenty-five  years  of 
age,  72  for  those  between  the  ages  of  twenty-five  and 
thirty  years,  87  for  those  between  thirty  and  forty  years, 
89  for  those  between  forty  and  fifty,  and  100  per  cent  for 
individuals  over  fifty  years  of  age. 

There  is,  of  course,  some  variation  in  statistics  re- 
ported by  different  observers.  This  is  due  in  part  to 
the  class  and  age  of  the  patients  examined  and  in  part 
to  slight  differences  in  the  basis  upon  which  the  diagnosis 
of  sepsis  is  made. 

Facts  which  seem  certain  from  evidence  now  at  hand 
may  be  summarized  as  follows :  Dental  sepsis  is  one  of 
the  commonest  of  the  chronic  active  infections  and  for 
this  reason  ranks  theoretically  as  a  very  frequent  cause 
of  ill  health.  The  ill  effects  of  the  lesions  frequently  ap- 
pear clinically  to  be  out  of  all  proportion  to  their  size, 
a  fact  which  may  be  explained  by  their  frequent  occur- 
rence in  the  form  of  blind  abscesses,  by  their  frequent 
localization  in  osseous  tissue,  which  allows  no  expansion, 


SUMMARY   AND    CONCLUSIONS  109 

and,  finally,  by  the  frequency  with  which  the  infected 
areas  are  exposed  to  pressure  transmitted  by  the  teeth 
during  mastication. 

Some  individuals  with  small  areas  of  sepsis  may  show 
many  serious  systemic  ill  effects,  while  others  with 
greater  amounts  may  apparently  suffer  less. 

Oral  sepsis  as  a  focus  of  chronic  active  infection  may 
be  a  source  of  ill  health  in  many  different  ways.  It  ma}' 
harbor  and  distribute  organisms  which,  under  certain 
conditions,  may  infect  other  tissues  and  give  rise  to  acute 
or  chronic  inflammatory  lesions.  It  may  have  a  toxic 
effect  with  ensuing  disease  in  both  normal  and  diseased 
organs.  This  effect  in  healthy  individuals  may  perhaps 
be  slight.  It  may  be  decidedly  harmful,  however,  in  in- 
dividuals who  are  depleted  by  disease,  injurious  habits, 
overwork,  or  age.  It  may  favor  the  advance  of  in- 
fectious diseases  due  to  organisms  distributed  from  the 
alveolar  process  as  a  primary  source  of  infection  and 
may  also  favor  the  advance  and  augment  the  symp- 
toms of  other  infections  which  are  in  no  wise  related  to 
it.  It  may  also  cause  functional  disturbance  in  rela- 
tively normal  organs  by  furnishing  an  alien  protein  to 
which  an  individual  may  have  become  highly  sen- 
sitized. In  the  same  way  it  may  increase  functional  dis- 
turbances due  primarily  to  organic  disease.  Finally,  it 
may  cause  local  pain,  referred  pain,  and  headache. 

The  immediate  therapeutic  result  which  follows  the 
eradication  of  oral  sepsis  varies  and  the  more  conserva- 
tive often  hesitate  to  promise  too  much.  Frequently  the 
result  is  excellent.  On  the  other  hand,  it  is  often  disap- 
pointing. It  is  likely  to  be  disappointing  if  the  removal 
has  been  incomplete,  or  if  other  coexisting  infections 
have  been  left  intact,  also  if  extreme  anatomic  changes 
have  been  brought  about  as  a  result  of  chronic  systemic 
infection.  The  best  results  are  obtained  in  those  in- 
stances where  the  systemic  effects  are  chiefly  toxic.  In 


110  ORAL   SEPSIS 

these  cases  a  brilliant  result  often  can  be  secured  within 
a  short  time. 

The  treatment  of  oral  sepsis  is  largely  a  dental  prob- 
lem, and  is  at  present  the  subject  of  much  interesting 
investigation.  Several  factors  must  be  considered  in  the 
choice  of  method,  namely,  adequacy  and  permanence  of 
result,  possibility  of  restoring  surfaces  for  mastication, 
time  and  expense  to  the  patient.  Time  and  expense  often 
make  extraction  of  teeth  with  damaged  roots  the  method 
of  preference.  In  addition  to  this,  it  is  the  safest  and 
surest  means  of  eradicating  sepsis.  Frequently  conserva- 
tive methods  are  justified,  however,  especially  if  the  re- 
sulting systemic  diseases  are  not  extremely  serious  and 
if  there  exists  no  constitutional  disorder  such  as  diabetes, 
severe  anemia,  etc.,  which  may  lower  resistance  to  in- 
fection and  decrease  the  likelihood  of  success. 

The  treatment  of  oral  sepsis  may  be  divided  into  three 
classes :  first,  treatment  of  existing  sepsis ;  second,  treat- 
ment of  defective  teeth  for  the  purpose  of  preventing 
sepsis ;  third,  treatment  of  children  with  the  view  of  ob- 
taining perfect  development  of  the  teeth  and  oral  cavity, 
thereby  avoiding  some  of  the  various  defects  which  even- 
tually lead  to  sepsis.  The  last  method  naturally  is  the 
best.  Eventually  it  is  also  the  cheapest  and  easiest. 
Under  ideal  conditions  prophylaxis  should  begin  in  early 
childhood  and  should  include  the  proper  handling  of 
every  abnormal  condition  of  the  mouth,  throat,  and  nose 
which  may  give  rise  to  mouth-breathing,  debility,  infec- 
tion, etc.,  and  in  this  way  interfere  with  the  proper  de- 
velopment in  the  architecture  of  the  throat,  nose,  jaw, 
and  teeth.  If  the  public,  as  well  as  physicians  and  den- 
tists, were  aware  of  the  serious  influence  which  defective 
teeth  have  on  the  development  and  health  of  the 
average  individual,  oral  prophylaxis  would  hold  the  im- 
portant place  in  preventive  medicine  that  it  so  richly  de- 
serves, and  the  result  would  be  economy  in  time  and  ex- 


SUMMARY   AXD    CONCLITSIOXS  111 

pense  to  the  patient,  increased  physical  and  mental  effi- 
ciency, a  greater  average  duration  of  life,  better  preser- 
vation of  the  tissues  in  old  age,  and  fewer  chronic  dis- 
eases. 


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INDEX 


Abscess,  alveolar,  21,  37 

acute,    pathology    of,   48 

symptoms  of,  48 
chronic,  pathology   of,  49 

symptoms  of,  49 
crowned    teeth    in    relation    to, 

45 

diagnosis  of,  39 
diagnosis      of,      in      roentgeno- 

grams,  50 
mode  of  onset,  47 
occurrence  of,  23,  37 
results    of    palliative    measures 
of      treatment      shown     in 
roentgenograms,   59-66 
root  remnants  in  relation  to,  46 
rupture     of,     into     antrum     of 
Highmore,      as     cause      of 
headache,   105 
source  of  origin,  37 
root  canal,  37 
gum  margin,   37 
statistics  regarding,  37-39 
symptoms  of,  22 
vital  teeth  in  relation  to,  39 
Abscesses,   relation  of,  to  improper 

filling  of  root  canal,   43 
Acute    alveolar    abscess,    pathology 

of,  48 

symptoms    of,    48 
Adenoids,    relation    of,    to    etiology 

of  oral  sepsis,  27 
Affinities  of  streptococci,  72 
Age  in  relation  to  incidence  of  in- 
fection   of    gums    and    al- 
veolar process,  22 
in  relation  to  oral  sepsis,  108 
Alien   proteins,    effect   of,   on  unin- 

fected  organs,  91 
Allergy,  85 

as  applied  to  infections,  87 
effects  of,  illustrated  in  action  of 

tuberculin,   85 

relation   of,   to    oral   sepsis,    87 
Alveolar  abscesses,  21,  37   (see  Ab- 
scess, alveolar) 

Amebae    in    chronic    lesions    of    the 
gum,  31 


Anaphylaxis,   91 

as  a  result  of  infection,  98 
oral  sepsis  as  a  cause  of,  99 
symptoms  of,  in  animals,  92 

in  humans,  92 
symptoms   of    chronic,    95 
Arthritis  in  cervical  spine,  defective 
teeth  as  source  of,  102 

B 

Bacterial  proteins,  sensitizatioii  and 
tolerance  for,  90 

Blood  stream  as  a  medium  for  car- 
rying infection,  42 

C 

Caries  in  relation  to  ill  health,  21 

Carious  teeth,  infection  of  food  by, 
21 

Causes    of    pyorrhea    alveolaris,    24 

Chronic  abscess,  pathology  of,  49 
symptoms   of,   49 

Chronic  infections,  immunity 
against,  71 

Chronic  irritation  or  trauma  as 
cause  of  pyorrhea  alveo- 
laris, 24 

Chronic  sepsis,  frequent  occurrence 
of,  106 

Conservative  methods  of  treatment 
of  alveolar  abscesses,  57 

Constitutional  conditions  which  in- 
crease susceptibility  of  the 
gums  to  infection,  25 

Crowned  teeth,  in  relation  to  al- 
veolar abscesses,  45 


I) 


Dental  sepsis,  dental  work  as  source 

of,  22 
therapeutic    effect    of     treatment 

of,   IS 
Dental  work  as  source  of  sepsis,  22, 

23 

Diseases  caused  by  streptococci,  74 
Diseases  of  the  skin,  in  relation  to 

oral  sepsis,  100 
Duration   of   sensitization,  94 


121 


122 


IISTDEX 


E 


Emetine  in  treatment  of  pyorrhea, 
31 

Extraction  of  infected  teeth,  effect 
of,   upon   metastatic  infec- 
tions,  88 
therapeutic  effect   of,  89 

F 

Filling    the    root    canal    to   the    tip 

of  the  apex,  importance  of, 

42 
Focal  infections,  ill  effect  of,  upon 

individuals     with     syphilis 

of  the  nervous  system,  80 
removal  of,  as  part  of  the  regime 

in  treatment  of  syphilis,  84 
Functional  disturbances  due  to  oral 

sepsis,  90 
oral    sepsis    in    relation    to,    100, 

101 

G 

Granulating  areas  in  bone,  ossifica- 
tion of,  and  its  meaning, 
52 

Gramiloma,  root  canal  as  source  of 
continuous  reinfection,  56 

Granulomata,  viability  of  organ- 
isms in,  56 


II 


Headache,  as  a  referred  toothache, 

104 

related   to   oral   sepsis,   102 
History  of   relationship  between  ill 

health  and  defective  teeth, 

17 


Immunity  against  chronic  infec- 
tions, 71 

Infected  areas,  healing  of,  55 

Infected  teeth,  therapeutic  effect 
of  extraction  of,  89 

Infected  tonsils,  relationship  to 
acute  symptoms  of  tabes 
dorsal  is,  case  illustrating. 
81 

Infection,    anaphylaxis    as    a    result 

of,  98 
frequency    in    gums    and    alveolar 

process,  22 

importance   of   lowered  resistance 
to,  32 


Infection — Cont  'd 

importance    of    primary    foci    in 

distributing,  74 
in  normal  individuals,  77 
influence  of   local   injury,   77 
metastatic,  71 

of  a  tissue,  relation  of  local  in- 
jury to,  75 

of  food   by   carious   teeth,   21 
of  root  pulp,   origin   of,  42 
of  vital  pulp,  42 
relation  of  lowered  resistance  to 

spread  of,   75 
spread  of,  in  relation  to  virulence 

of  organism,  75 
Infections,    allergy    as    applied    to, 

87 
in  remote  organs,  relation  of,  to 

oral  sepsis,  88 

Inflammatory  reactions  in  distant 
organs,  relation  of,  to  oral 
sepsis,  88 

Influence  of  one  infection  upon  an- 
other, 79 

Injury,  local,  in  determining  site  of 
infection  and  effect  of  an 
organism,  76 

relation   of,  to   infection   of   a 
tissue,   75 

Interpretation  of  roentgenograms. 
50 


Lowered    resistance,    effect    of,    on 

metastatic  infection,  71 
relation   of,    to    spread   of    infec- 
tion from  a  primary  focus, 
75 

M 

Mastication,  poor,  in  relation  to  di- 
gestion, 21 

Metastatic  infection,   71 

effect    of    extraction    of    infected 

teeth  upon,  88 
from  a   primary  focus,   71 
importance    of    oral    sepsis    as    a 
source  of,   78 

Microorganisms  as  cause  of  pyor- 
rhea alveolaris,  24,  28 

Mouth-breathing  in  relation  to  oral 
sepsis,  27 

Myositis  in  muscles  of  the  neck,  de- 
fective teeth  as  source  of, 
102 


INDEX 


123 


Neuralgia,  oral  sepsis  as  source  of, 

104 
Xonrelated    infection    as    influenced 

by  oral  sepsis,  79 


0 


Oral    prophylaxis,    110 
Oral 

sepsis,  adenoids  in  relation  to,  27 
as  a   source   of   metastatic   infec- 
tion, 78 

as  cause  of  neuralgia,  104 
dental  work  as  cause  of,  23 
diseases  of  the  skin  in  relation  to, 

100,  101 
frequency  of,  106 

as     a     cause     of     anaphylactic 

phenomena,  99 

functional  disturbances  due  to,  90 
general    paresis    relieved    by    re- 
moval of,  82 

headache  related  to,  102 

mouth-breathing  in  relation  to, 
27 

nonrelated  infection  as  influenced 
by,  79 

occurrence  of,  in  different  classes 
of  individuals,  20 

pathology  of,  in  relation  to  in- 
actions in  distant  organs, 
88 

relation  of  age  to,  108 

relation   of,   to  allergy,   87 

relation  of,  to  inflammatory  re- 
actions in  distant  organs, 
88 

symptoms  of,  dependent  on  sen- 
sitization,  tolerance,  and 
rate  of  growth  of  organ- 
isms, 91 

tabes  dorsalis  relieved  by  removal 
of,  case  illustrating,  82 

tonsils   in   relation   to,   27 

toxic  effect  of,  85 

toxic  symptoms  relieved  by  treat- 
ment of,  99 

treatment  of,  78 

Organisms     in     granulomata,     via- 
bility   of,    56 

Ossification     of     granulating    areas 
in   bone    and    its   meaning, 
52 
Osteomyelitis  of  jaw,  26,  49 


Paresis  relieved  by  removal  of  oral 
sepsis,  case  illustrating,  82 
Primary  foci,  importance  of,  in  dis- 
tributing infection,  74 
Primary   focus   of   infection,   result 
of    removal    of,    upon    sys- 
temic  infection,   78 
Protein  sensitization  as  observed  in 

humans,  93 

Vaughan's  theory  of,  96 
Proteins,   alien,   effect   of,   on   unin- 

fected  organs,  91 
Pus,   swallowing   of,   in   relation   to 

digestion,   21 
Pyorrhea     as     factor     in     systemic 

disease,  21 

Pyorrhea  alveolaris,  24-36 
causes  of,  24 

chronic  irritation  or  trauma,  24 
conditions     preventing     normal 
massage   of   the   gums  and 
cleaning  of  the  teeth,  24 
constitutional   conditions   which 
increase    the    susceptibility 
of   the   gums   to   infection, 
25 

microorganisms,  24 
unsanitary  conditions,  24 
Pyorrheal  abscesses,  29,  40 


Radiolucent  areas,  interpretation 
of,  52 

Relation  of  selective  affinity  to  vir- 
ulence of  organisms,  74 

Regenerated  bone,  structure  of,  53 

Resistance  against  infection  may  be 
lowered  by  infection,  34 

Resistance  to  infection,  lowered,  in 
relation  to  pyorrhea,  32 

Result  of  injury  to  tissues  and 
abuses  to  metastatic  infec- 
tion, 77 

Roentgenograms,    interpretation    of, 

50 

showing  the  result  of  palliative 
measures  of  treatment  of 
alveolar  abscesses,  59-66 

Root  canal,  importance  of,  as  source 
of     continuous    reinfection 
granuloma,  56 
importance  of  filling  to  the  tip  of 

the  apex,  43 

improperly  filled,   relation   of   ab- 
scesses to,  43 
work,  examples  of,  67-70 


124 


INDEX 


Root  pulp,  origin  of  infection  of,  42 
Root  remnants  in  relation  to  alveo- 
lar abscesses,  46 

Rupture  of  alveolar  abscess  into  an- 
trum  of  Highmore,  105 

S 

Sensitization  against  living  tubercle 

bacilli,  86 
against  proteins  not  of  bacterial 

origin,  91 

against  tuberculin,  86 
and   tolerance   for   bacterial   pro- 
teins, 90 
duration  of,  94 

to  alien  albumens,  method  of,  93 
Sepsis  (see  Oral  sepsis) 
Shock,  anaphylactic,  95 
Skin  diseases  in  relation  to  oral  sep- 
sis, 100 

Statistics     regarding     alveolar     ab- 
scesses, 37-39 
Streptococci  as  cause  of  metastatic 

infection,  72 
diseases  caused  by,  74 
selective  affinities  of,  72 
Structure  of  regenerated  bone,  52 
Syphilis   of  the   nervous  system,  ill 
effect    of    focal     infection 
upon    individuals   with,    80 
Syphilis,    removal    of    focal    infec- 
tions as  part  of  regime  in 
treatment  of,  84 

Systemic  infection,  character  of  in- 
fection attributable  to  oral 
sepsis,  78 

result    of   removal    of    a   primary 
focus  of  infection  upon,  78 


T 


Tabes  dorsalis,  acute  symptoms  of, 
relationship  of,  to  infected 
tonsils,  81 


Tabes  Dorsalis — Cont  'd 

relieved   by  removal   of  oral   sep- 
sis, case  illustrating,  82 

Therapeutic  effect  of  extraction  of 

infected  teeth,  89 
of  treatment  of  dental  sepsis,  18 

Tissue,  relation  of  local  injury  to 
infection  of,  75 

Tonsils,    infected,    case    illustrating 
relation  of,  to  acute  symp- 
toms of  tabes  dorsalis,   81 
relation    of,    to    etiology    of    oral 
sepsis,  27 

Toxic  effect  of  oral  sepsis,  85 

Toxic  symptoms  often  relieved  by 
treatment  of  oral  sepsis,  99 

Transmutation  of  species  of  strep- 
tococci, 72 

Trauma  as  cause  of  pyorrhea  al- 
veolaris,  24,  32 

Treatment  of  alveolar  abscess,  con- 
servative methods  of,  57 

Treatment  of  oral  sepsis  does  not 
always  give  relief  hoped 
for,  78 

Tubercle  bacilli,  sensitization  against 
living,  86 

Tuberculin  reaction  as  illustration 
of  allergy,  86 


Vaughan's  theory  of  protein  sensi- 
tization, 96 

Viability  of   organisms   in  granulo- 
mata,  56 

Virulence   of   organisms  in  relation 
to  selective  affinity,  74 

Virulence,  relation  of,  to  spread  of 
infection,  75 

Vital  pulp,  infection  of,  42 

Vital  teeth,  abscessed,  39 
Vincent's  angina,  30 


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